Korean Med Educ Rev > Volume 26(Suppl1); 2024 > Article
Chun: Cognitive Constructivism in the Development of Medical Education

Abstract

This study introduces cognitive constructivism in reference to its emergence in the development of medical education. The main concepts of cognitive constructivism as they relate to knowledge construction and the learner’s process were described, and cognitive constructivism as a learning theory was examined in its capacity to help interpret the phenomenon of medical education. Piaget’s theory of cognitive constructivism and Ausubel’s meaningful learning theory were applied in an attempt to explore the role of students and educators, curriculum, and teaching and learning in medical education from a cognitive constructivist perspective. When faced with new information, learners compare it with the existing schema to understand, and in order to resolve conflicts caused by inconsistencies in the information, learners incorporate assimilation and accommodation to help maintain equilibration. Therefore, instructors must meaningfully connect new content to the learner’s existing schema and make endless efforts to satisfy learners’ intellectual curiosity. The basic premises of medical education content is a suitable subject of meaningful learning. A learner who already possesses well-structured knowledge is likely to experience meaningful learning and a richer intellectual experience. Therefore, it is necessary to organize the curriculum strategically and elaborately so that learners can have an improved and effective learning experience.

Introduction

In the fields of psychology and education, behaviorist scholars once referred to our mind or psyche as the “black box.” Subsequently, we have experienced a paradigm shift from the behaviorist to the constructivist perspective, both philosophically and educationally, culminating in the rise of constructivism [1]. Although limitations persist, advancements in neuroscience and behavioral science have enabled us to move beyond treating the processes within our minds as an impenetrable black box. Furthermore, there is a consensus that a variety of perspectives, including postmodernist approaches, are essential for explaining our thoughts and actions, transcending the notion of absolute knowledge in structure or perception. Adopting postmodernist approaches in education involves recognizing the diversity of academic disciplines and embracing multiple perspectives. Notably, this has facilitated a range of learner-centered initiatives and methods, moving away from the traditional, predominantly teacher-centric transmission of absolute knowledge. Discussing various learning theories in medical education is of great significance from both philosophical and practical standpoints. This discussion has provided support for educational endeavors grounded in theory as well as for hands-on teaching practices.
The numerous questions and answers in medicine, much like the ongoing challenges of exploration, are largely based on knowledge and expertise accumulated over time. Similarly, the answers to frequently asked questions by medical educators, such as “Why?” and “How?” are rooted in theory and evidence. It is therefore common in medical education to rely on learning theories or teaching theories to understand the various phenomena, efforts, and outcomes being addressed. Additionally, to help learners achieve better outcomes and maintain continuous self-improvement, instructors should understand the principles of learning, namely educational theories, as well as the learners themselves. This understanding facilitates the implementation of effective teaching methods or educational programs [2]. Driscoll [2] highlighted that effective teaching requires both descriptive and prescriptive learning theories. Descriptive theory examines the outcomes that arise when specific conditions and methods are applied, whereas prescriptive theory guides which methods should be used to achieve desired outcomes under particular conditions.
Discussing the core concept of constructivism, which centers on the construction of knowledge and its subject—the process of knowledge formation in learners—is of paramount interest to educators. In this context, the author aims to provide an overview of the background that precipitated the emergence of cognitive constructivism, the concepts it encompasses, and the associated theories. Additionally, the author intends to explore various phenomena in medical education through the lens of cognitive constructivism. Moreover, the author plans to discuss the future developmental direction of medical education as informed by cognitive constructivism.

The emergence of cognitive constructivism

To understand the background of cognitive constructivism’s emergence, it is necessary to examine the learning theories that succeeded behaviorism. Mukhalalati and Taylor [3] provided a guide for healthcare educators based on adult learning theories. They synthesized these theories from a total of 436 academic papers, selecting 110 relevant papers for their analysis. The summarized content is presented in Table 1. According to this synthesis, seven predominant learning theories have been identified: instrumental learning theories, which include behaviorism, cognitivism, and experiential learning; humanistic learning theories, exemplified by self-directed learning; transformative learning theories, highlighted by critical reflection; social learning theories, represented by the zone of proximal development, situated cognition, and community of practice; motivational learning theories, which include self-determination theory and expectancy theory; reflective learning theories, characterized by reflection on action and reflection during action; and constructivist learning theories, which encompass cognitive constructivism and socio-cultural constructivism.
In contrast, Doolittle and Camp [4], aiming for a more concise classification of learning theories, identified three dominating theories that have shaped education from the 1800s to the present day. The first is behaviorism, which defines learning as stimulation and response. The second is information processing, or cognitivism, which defines learning through information processing. The third is constructivism, which defines learning through the construction of knowledge.
The first of these, behaviorism, is exemplified by the ABC model proposed by psychologist Burrhus Frederic Skinner [5]. This model posits that specific behaviors are influenced by antecedents and consequences, which correspond to stimuli and responses, respectively. Behaviorists disregard the cognitive or mental processes occurring between the stimulus and the response, referring to them metaphorically as the “black box.” Their primary interest lies in the observable stimuli and responses, or the antecedents and consequences of behavior. They largely ignored the internal processes of the human mind that underlie these stimuli and responses. For behaviorists, cognitive processes were outside the realm of observation or research; they were considered a black box that either did not warrant exploration or whose internal mechanisms were inscrutable. Consequently, behaviorists showed no concern for the subjective understanding or self-directed attributes of learners.
Surprisingly, many aspects of the learning phenomenon are still explained by behaviorist theories, with terms like “praise” and “reward” remaining prevalent. The influence of behaviorism is likely to continue. However, there is a growing need for research from alternative perspectives that challenge the behaviorist view of learners as passive recipients. This need is closely associated with an interest in the “black box” of cognition. Cognitive theorists, intrigued by our mental processes and functions, conduct a range of studies on cognition, including information processing, memory, thinking, reasoning, and problem-solving. As a result, a diverse array of theories on learning mechanisms has surfaced, contributing to advancements in computer science and artificial intelligence.
With the efforts of cognitive theorists, the once opaque “black box” of the human mind began to be gradually illuminated, leading to new explorations and challenges. As interest in the philosophical and cognitive underpinnings of these theories grew, so too did reflections on the nature of knowledge and its subjects. This intellectual climate gave rise to constructivism, which, in the postmodern era, was adopted as both an epistemological framework and a psychological and educational theory. The philosophical shift brought about by constructivism offers a fresh perspective on education. In contrast to the pre-constructivist era, which upheld absolute and objective knowledge, the post-constructivist era acknowledges that knowledge is personally constructed and emphasizes relativistic viewpoints. Since its inception, constructivism has become a substantial and pervasive influence in the field of education.
Above all, constructivism is both a philosophical epistemology and a psychological theory [3]. In the field of education, which is deeply rooted in psychology, constructivism is adopted as a practical pedagogical and learning theory. Its application extends beyond the description of educational phenomena to the prescription of instructional methods. The evolution of constructivism is characterized by the emergence of two distinct strands: cognitive constructivism and social constructivism. These branches diverge based on their respective views on how knowledge is constructed. Chu [6] notes that while both cognitive and social constructivists agree that knowledge is actively constructed and restructured as a child develops, they differ in their emphasis. Cognitive constructivists focus on the physiological and psychological processes of the learner, whereas social constructivists highlight the role of social factors in learning. Prominent figures such as cognitive constructivist Jean Piaget and social constructivist Lev Semyonovich Vygotsky have introduced learning theories that address child development. They offer varying insights into cognitive construction and information processing. Their contributions have established constructivism as a significant paradigm, influencing not only philosophy but also the disciplines of psychology and education.

The key concepts and principles of cognitive constructivism

Piaget [7] regarded students as “little scientists,” a term that describes individuals who actively construct conceptual frameworks and engage in rigorous learning to encode information in memory. Piaget’s primary interest lay in how individuals perceive objects or information and the manner in which they organize knowledge. He posited that humans cannot directly obtain usable information; rather, they must construct their own knowledge [8]. In other words, cognitive constructivism focuses on the process where individual learners autonomously and in diverse ways construct knowledge.
Cognitive constructivism is recognized for its emphasis on physiological and psychological mechanisms, largely due to Piaget’s explanation of knowledge construction through the concept of biological equilibrium, which involves maintaining balance. Central to this process are the concepts of “schema,” “assimilation,” “accommodation,” and “equilibration” [7-9]. Initially, learners develop a cognitive framework, or “schema,” which serves to integrate and organize information. Schemas represent organized patterns of thought or behavior. As individuals mature from childhood to adulthood, they amass a wide array of schemas that span from tangible to abstract concepts [10]. Piaget [7] identified four stages of development: the sensorimotor stage, the preoperational stage, the concrete operational stage, and the formal operational stage. Throughout these stages, children refine and solidify their schemas via assimilation and accommodation. He also highlighted the pivotal role of language as a crucial tool in this developmental process.
In this context, assimilation and accommodation are mechanisms that resolve internal conflicts when new information is compared with existing schemas. If new information is consistent with the existing schema, the learner adapts through assimilation. Conversely, when new knowledge does not align with the existing schema, learners must accommodate by modifying their schemas to incorporate the new information. This process of adaptation is known as accommodation. Both assimilation and accommodation strive to maintain a state of equilibrium, an internal cognitive balance, by resolving conflicts that emerge during the process of understanding and integrating new information. This concept of maintaining biological equilibrium suggests that our knowledge acquisition process is a survival mechanism, determining whether our knowledge base deteriorates or contributes to our continued existence. Thus, this theory provides a compelling explanation for the necessity of engaging in lifelong experiences and learning.
Piaget’s theory provides both a theoretical foundation and practical considerations for how educators should present information to learners. In practice, instructors should assess the learners’ existing knowledge base when structuring educational content and materials. They ought to design activities that provoke cognitive conflicts, or disequilibrium, at an appropriate level, thereby encouraging the processes of assimilation and accommodation within the learner. Conversely, it is equally important to supply learners with familiar and relevant materials that support comfortable knowledge acquisition while they navigate disequilibrium. Consequently, effective teaching requires the ability to leverage both methods of knowledge construction, marking it as a critical competency for educators. Recognizing individual differences among learners is also of paramount importance. The instructional methods used in e-learning, which often incorporate individualized learning, can be viewed as an application of the principles of cognitive constructivism. Thus, developing teaching and learning activities based on cognitive constructivism is deeply rooted in an educational philosophy that prioritizes the learner. This approach necessitates a profound understanding of the cognitive and psychological attributes of learners. It is therefore vital to recognize that the term “student-centered education,” which we have frequently used, is a principle that has emerged with the active support of cognitive constructivism. The emphasis many educators place on understanding learners can also be understood through the lens of cognitive constructivism.

Medical education from a cognitive constructivist perspective

While traditional classroom education remains a cornerstone of higher education, there has been a persistent focus on personalized and individualized instruction that caters to the unique characteristics and capabilities of each student. The core ideas and tenets of cognitive constructivism, as previously outlined, have significantly influenced shifts in educational paradigms or have been instrumental in explaining such changes. Cognitive constructivism extends beyond traditional classroom lectures to encompass innovative multimedia resources and a variety of active learning strategies. This is attributed to its status as a fundamental learning theory centered on the learner as the active creator of knowledge. The following discussion examines the pertinence of cognitive constructivism within the educational sphere, where behaviorism and cognitivism continue to hold sway, with a particular focus on its impact on medical education.

1. The learner

In a reflective essay on 25 years of constructivism in medical education, Dennick [11] endorsed Piaget’s view that our experiences in medical education involve continuously assimilating or accommodating existing knowledge or concepts. This suggests that our interactions with the world are based on the assimilation and accommodation of prior experiences or knowledge, leading to knowledge acquisition through cognitive processes. Dennick [11] posited that recognizing an imbalance between assimilation and accommodation prompts the formulation of questions and explanations. The act of generating various proposals and hypotheses, he argued, cultivates a form of imagination or creativity. Essentially, he saw individuals as scientists who construct new knowledge by interpreting existing knowledge and extracting meaning from the world. His perspective is in line with the prevailing views of cognitive constructivists and offers valuable insights into how we should perceive our students.
Learners are individuals with their own unique knowledge structures and latent potentials. To effectively implement cognitive constructivism in medical education, it is essential to adopt an adult education perspective. The educational processes and assessments we aim to administer or oversee are often similar to those designed for children and adolescents, which may not be entirely suitable for adult learners. Adult learners exhibit characteristics that are markedly different from those of children and adolescents, and there is also a range of learning differences between younger and older adults. For instance, young adults tend to engage more actively in deep-level information processing, such as elaboration and organization, in comparison to older adults [12]. In general, adult learners demonstrate intrinsic motivation, a strong desire for self-improvement, and a profound interest in learning, which sets them apart from younger learners [12]. They typically recognize the value of learning, see themselves as learners, understand the significance of their experiences, and are both ready and motivated to learn [13]. Acknowledging participants in medical education as adult learners means recognizing their considerable cognitive potential and the fundamental skills of students entering medical school. Moreover, it is crucial to remember that fostering preparedness and motivation for learning among medical students is just as important as the transmission of knowledge.
Ausubel [14] also considered interest and motivation to be crucial in learning, emphasizing that effective assimilation and accommodation are not possible without active learner engagement. Therefore, there is a need to shift some of the focus from structuring and assessing educational content and outcomes to enhancing learning experiences and motivation in medical education. In the context of medical education, where there is a high volume of learning material and intense study demands, it is particularly important to emphasize efforts to promote intrinsic motivation, curiosity, and active learning. In medical education, intrinsic motivation and curiosity can stem from the interrelationships among knowledge structures. The restoration of relationships, such as tools that solidify and expand learners’ cognitive structures, the connections between knowledge and background information, and the alignment of goals and anticipated outcomes, is critically needed in medical education. The primary mechanism for establishing and maintaining such relationships is the concept of “integrated education.” Integrated education is a pivotal tool for building and sustaining these relationships in the realm of medical education. The interconnectedness between basic medicine, clinical medicine, and the humanities and social sciences should not imply fragmented knowledge and experiences. Instead, it should lead to the formation of integrated knowledge and the accumulation of unified learning experiences. The current learning content plays a crucial role in establishing strong connections regarding its future application in real medical situations and its potential utilization for the benefit of society or the community. Therefore, for those who still question the necessity of integrated education, it is essential to explain the powerful learning effects that stem from the cognitive constructivist perspective, which emphasizes the structured aspects of knowledge and the robust interrelatedness and integration of knowledge.
Sometimes, we metaphorically describe learners as blank sheets of paper. This metaphor suggests that their learning outcomes can be as varied as a sketch’s design or the choice of different colors, depending on instructional design. However, this positive perspective also carries an implicit controlling element, suggesting that learners are dependent on the instructor’s abilities rather than highlighting the importance of learner autonomy and effort. It subtly emphasizes the instructor’s role in shaping educational outcomes in a positive light. Contrary to this metaphor, within the cognitive constructivist framework, learners are not seen as blank sheets of paper. Rather, it is understood that each learner brings their own unique “sheet of paper,” which varies in size, shape, color, and content. Acknowledging this means recognizing the diversity in how learners construct knowledge, their different levels of prior knowledge, and the potential misconceptions they may harbor. Accepting this view naturally leads to the need for strategies to understand how learners form knowledge structures, assess their current levels of understanding, and identify any misconceptions. In essence, this calls for an assessment process akin to formative assessment. Therefore, within the cognitive constructivist framework, embracing this initial premise leads to the realization that formative assessment is not merely an evaluation tool, as outlined in the Accreditation Standards of KIMEE 2019 (ASK2019) for medical education. Rather, it is an essential part of the educational process, aimed at verifying learners’ internal knowledge construction rather than solely measuring their achievement levels and the performance of instructors [15].

2. Curriculum and teaching & learning

Hunter [16] emphasized the role of instructors as facilitators rather than as central knowledge transmitters, stimulating learners’ prior knowledge and fostering both assimilation and accommodation. This approach is consistent with the principles of social constructivism, which places emphasis on the facilitator’s role. In cognitive constructivism, the facilitator’s role, as described by Hunter, involves promoting internal cognition and aiding in the interpretation of the environment as well as in the formation of new knowledge structures.
Unless absolute grading is implemented across all medical education lectures, students are typically assessed with relative rankings or scores, which can create a competitive atmosphere akin to racehorses sprinting toward the singular goal of achieving a high score. However, when we acknowledge that students are unique individuals, each with their own set of skills, perspectives, and learning styles, and we embrace the role of the instructor as a facilitator of knowledge construction rather than a mere disseminator of information, the approach to teaching fundamentally changes. This paradigm shift encourages a broader consideration of diverse teaching methods and shifts the focus from what the instructor delivers to what the students learn. This change is most apparent when articulating learning outcomes. In the past, learning outcomes were often described in objective terms that centered on the instructor, detailing what they intended to teach or what they expected students to learn. However, in the formulation of learning objectives or outcomes at most medical schools today, the emphasis has shifted to the learner. Now, the outcomes describe what the students will be capable of doing by the end of the course. For those who still question the value of revising traditional learning objectives, a more proactive response is warranted. From the cognitive constructivist viewpoint, it is essential to articulate the degree of attention we devote to learners and how we have reoriented educational activities to be learner-centered. Furthermore, we must recognize that the change in our language reflects a deeper transformation in our cognition and perception, echoing Piaget’s assertion about the profound influence of language.
David Paul Ausubel is a cognitive constructivist scholar who proposed that instructional materials, educational content, and lesson formats should be designed to tap into the learner’s cognitive structure, focusing on the formation and transformation of schemas to aid in cognitive organization. Ausubel [17] emphasized the importance of guiding new learning material in a way that meaningfully connects with the learner’s existing cognitive structure, thus advocating for meaningful learning. The core of meaningful learning is enabling learners to comprehend and easily recall knowledge over an extended period, which allows them to apply what they have learned in various scenarios. Additionally, meaningful learning seeks to move away from mechanical, rote-style teaching and the fragmented memorization of knowledge, instead promoting self-directed understanding and the expansion of knowledge among learners. In particular, Ausubel [17] noted that meaningless and inappropriate learning tasks, along with gaps in learners’ existing knowledge and motivation, can impede meaningful learning. To promote meaningful learning, he underscored the necessity of eliminating arbitrary or unsuitable learning tasks and providing tasks that align with the learner’s cognitive structure and are highly relevant.
A proposition by Ausubel [17] has had a significant impact on the design and substance of educational materials and curricula. In medical education, as in other specialized fields, there is a challenge in structurally organizing the curriculum in a coherent manner that respects the sequence and scope of the discipline, given its independent scholarly structure and detailed specialization. The task of designing a medical curriculum is universally challenging; experts in independent and highly specialized areas often view all content within their domains as essential. As a result, identifying the foundational knowledge that underpins meaningful learning is an arduous task. Furthermore, it is difficult to facilitate effective learning that not only encompasses the agreed-upon core content but also systematically organizes subsequent knowledge based on scope and sequence. This must be done while ensuring that the material is easily retained and transferable, and that learner motivation is maintained during actual implementation. Most medical education programs aim to achieve an integrated curriculum. However, even organizing content to reflect academic interconnections is a daunting task. Efforts to optimize these interconnections, ensuring coherence among the natural sciences, basic medicine, clinical medicine, and practical clinical experiences, are often considered an art form. A well-constructed integrated curriculum should significantly assist learners in forming and organizing knowledge, offering a clear advantage over fragmented educational approaches. Additionally, the curriculum should include effective and efficient learning activities and experiences that empower learners to integrate and apply a broad range of educational content.
Next, let us shift our focus to the curriculum and classes. Medical education is structured based on the premise of “being able to perform primary care,” ensuring that all instructional content is designed with practical application in future medical scenarios in mind. As such, the material learned by students lays a meaningful foundation for the tasks they will undertake in the future. However, the content within courses can sometimes be disjointed, and the explanations of how different topics relate to one another may be insufficient. To address this issue, universities appoint designated professors to oversee courses and promote collaborative communication among all participants in the educational process. This is essential for the effective implementation of integrated education. According to the ASK2019 standards, it is policy for all medical school professors to be well-versed in the entire curriculum. Basic standards have been set to support professorial activities in this regard. This approach stems from the need to overcome the aforementioned challenges. Medical education today cannot be confined to the scope of an individual course or subject. Its effectiveness is measured by the degree to which it is systematic, interconnected, and collaboratively managed.
From the perspective of cognitive constructivism, the most pressing improvement needed in medical education is the restoration of the interconnectedness of educational content. This involves emphasizing existing relationships, making learners aware of these connections, and organizing and delivering course content with these relationships in mind. Ausubel [14] suggested three approaches to achieve this educational connectedness: learning by acquiring a broader and more general superordinate concept that incorporates new knowledge within existing knowledge or concepts and principles, learning sub-concepts of previously acquired general concepts, and integrating concepts at a similar level to those already learned. A single class session is never isolated; it is always linked to previous and subsequent sessions. It is essential to clarify how each lesson’s content is ultimately dependent on, extended from, and connected to certain concepts and principles to create an effective cognitive structure for both the instructor and the learner. This concept is in harmony with the elaboration theory. According to Charles M. Reigeluth’s elaboration theory, strategies such as progressing from simple to complex, sequencing elements before and after learning, providing summaries, synthesizing information, using analogies, stimulating cognitive strategies, and allowing learner control are recommended as methods of elaboration. These strategies are known to enhance understanding and are considered essential teaching methods [18].
Lim [19] conducted formative research grounded in Reigeluth’s instructional design theory to develop a deeper conceptual understanding of lesson design. The study revealed that learners showed a preference for a learning presentation that adhered to a hierarchical process. This process involved presenting and explaining the learning content, followed by demonstration and evaluation. Providing guidance on the method of presentation and granting learners control over elements such as sequence and pace resulted in more favorable evaluations. Strategies such as practice, evaluation, and feedback were acknowledged as effective. Sequencing, which pertains to the order in which experiences are presented, and summarization were also viewed as beneficial. Lim [19] proposed that introducing cases that embody the concept prior to teaching the concept itself could enhance learning effectiveness. The call for additional real-world examples during lessons, references to instructors’ experiences or relevant events, and consistent reinforcement of the interconnectedness of lesson content are all rooted in the principles of cognitive constructivism. However, how many of these elaboration strategies are actually employed in medical education lessons remains to be seen. To develop a faculty development program aimed at improving teaching skills, it is essential to offer detailed guidance on elaboration strategies that foster the fundamental cognitive structures in learners. Cognitive constructivism not only informs our understanding of knowledge but also serves as a learning theory and a vital component of practical and effective teaching methods.

Conclusion

Next, let us explore how cognitive constructivism can be extended and applied in medical education. While constructivism has garnered considerable interest in psychology and education, its exploration within medical education has been comparatively scarce. Research in this area has mainly concentrated on cognitive theories as they relate to cognitive therapy or psychological treatment. The emphasis in medical education has been more on cognitive theories and developmental research, with less attention given to cognitive constructivism [11,20-22].
From the perspective of cognitive constructivism, learners are understood to possess an inherent basic structure of knowledge. To phrase it starkly, knowledge can be viewed through the lens of a “rich get richer, poor get poorer” dynamic. Learners with comprehensive, general, and well-structured existing knowledge are more likely to engage in meaningful learning, leading to richer intellectual experiences. They have ample resources for assimilation and accommodation, enabling them to engage in cognitive efforts akin to those of true scientists. The question then arises: How can we assist learners during the 6-year span of medical education to establish a foundational knowledge structure? How can we encourage the expansion and growth of their existing knowledge base, and to what extent can we aid in the formation of numerous schemas? These are critical questions to consider when designing education programs that must be both strategic and sophisticated. Such programs may be defined and implemented through competency-based or outcome-based education, or those centered on clinical presentation. Regarding educational methods, techniques such as group discussions, journaling, portfolio development, and critical appraisal can all be woven into medical education grounded in cognitive constructivism.
Additionally, leveraging adult experiential learning theory for healthcare professional education is indeed feasible by applying the model by Kolb [23]. This model outlines a cyclical process that includes four stages: concrete experience, observation and reflection, abstract conceptualization and generalization, and the application and testing of concepts in new situations [23]. At any given moment, learners are engaged in a dynamic cycle of experiencing, reflecting, conceptualizing, and testing. Acknowledging that their knowledge structures are in a state of flux, shaped by the learning materials, teaching methods, and educational content we provide, can be a powerful motivator. It can reignite the passion for education and support the sustainability of ongoing educational endeavors. From the standpoint of cognitive constructivism, the greatest challenge in medical education is the relentless task of integrating the rapidly evolving medical landscape and the influx of new knowledge into educational content and learning experiences. As the world and its body of knowledge continue to expand, so too will our diverse efforts rooted in cognitive constructivism.
Reflection on the role of educators as cognitive constructivists is crucial in adapting to changes in the educational environment. The shift to online education, spurred by the coronavirus disease 2019 (COVID-19) pandemic in 2020, has brought about widespread changes in how education is delivered globally. As this transition unfolds, some online educational approaches will mirror the success or outcomes of traditional in-person instruction, while others may encounter setbacks or disappointments. The author posits that reflective processes grounded in cognitive constructivism should inform both the triumphs and challenges of online medical education within medical schools. The medical education sector is grappling with difficulties in creating video content for learning and condensing educational materials for online platforms. Furthermore, orchestrating real-time video-based education introduces an entirely new set of challenges. The author shares insights and observations from the response to COVID-19 in medical education, emphasizing the importance of a reflective, cognitive constructivist approach.
The amount and level of existing knowledge among learners naturally became a concern. With the loss of face-to-face interaction, it became necessary to consider learner attributes and anticipated responses in advance. This raised the fundamental question of what level of content to deliver and how best to deliver it. These considerations led to discussions about the quantity and quality of education, and we also came to realize how our trusted knowledge delivery systems could sometimes be perceived as boring or useless. The inability to see students in person piqued my interest in the inner workings of these invisible learners and how they organize their knowledge.
As challenges with non-face-to-face practical training emerged, universities sought various alternatives to traditional hands-on sessions. Yet, it is clear that no approach can match the fulfillment derived from in-person practical training unless online practices are supplemented with sophisticated programs like virtual reality or augmented reality. The inherent limitations of these systems or technological shortcomings often result in barriers and discomfort in conveying knowledge, forcing educators to adapt to new teaching methods. This raises a critical question: How can we improve student learning? Are students truly small, autonomous, and proactive scientists? From a Piagetian perspective, how can we deliver content that encourages narrative and adaptation to facilitate individual learning outcomes, thereby fulfilling and igniting their intellectual curiosity? Furthermore, in line with John Dewey’s philosophy, how can we assist them in comprehending the world of medicine and healthcare through experiential learning?
The theoretical strength of cognitive constructivism lies in its ability to provide substantial guidance for the questions posed earlier. By conceptualizing students beyond the unseen screen, our content and efforts to enhance their learning have become tangible. The request from students to highlight the pointer on the recorded presentation screen was a surprisingly refreshing insight. For instructors’ educational efforts to resonate with learners’ understanding and language, the learning experience must be crafted from the learners’ perspective and knowledge base. Furthermore, instead of questioning whether students are truly small, autonomous, proactive scientists, we can create learning experiences that genuinely stimulate and satisfy their curiosity and desires by believing in them as true young scientists.
Most importantly, effective individualized learning, self-directed cognitive development, and meaningful learning all require time and effort to foster. Cognitive constructivism remains a foundational theory in learner-centered education, including education based on e-learning. As such, it is imperative for instructors to recognize and monitor the knowledge construction processes of their learners. Instructors, much like their students, must continually build their own understanding of teaching and learning methodologies. Furthermore, it is crucial to acknowledge that patients, who are also a key educational demographic, are learners in their own right—expanding their knowledge about their conditions and themselves. Therefore, I advocate for additional research into the applications of cognitive constructivism in the context of patients and medical practices.

NOTES

Conflict of interest

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

Authors’ contribution

Kyunghee Chun: collected data, wrote the manuscript, compiled the bibliography, and conducted the overall writing of the paper.

Acknowledgments

I would like to express my sincere gratitude to Young Hwan Lee, Tae Hee Lee, Mi-Hye Kwon and Young-soon Park for their invaluable guidance and support throughout the entire research process.

Table 1.
Categorization of learning theories
Learning theory Subcategory
1. Instrumental learning theories Behavioral theories
Cognitivism
Experiential learning
2. Humanistic theories or facilitative learning theories Self-directed learning
3. Transformative learning theories Critical reflection
4. Social theories of learning Zone of proximal development
Situated cognition
Communities of practice
5. Motivational models Self-determination theory
Expectancy valence theory
Chain of response model
6. Reflective models Reflection-on-action
Reflection-in-action
7. Constructivism Cognitive constructivists
Socio-cultural constructivism

This table is a summary on the categorization of learning theories of Mukhalalati and Tayler [3].

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