Introduction
There is no single overarching theoretical framework that accounts for how we learn
in all situations. There are many theories of how we learn from our experiences and
there are many theories of what experiences are. We know that we do learn and that
we have knowledge but there is no consensus on the relationship between the mechanism
by which our brains learn and the optimal way in which we should be taught. In other
words there is no necessary connection between epistemology and pedagogy. We seem
capable of learning from a wide variety of pedagogical processes and although there
is empirical evidence that some ways of learning are more effective than others in
specific situations no one pedagogical method dominates. However, reflecting on twenty
five years as a medical educationalist I have come to the conclusion that there is
one framework that makes more connections between different epistemological and pedagogical
theories than others and that could have support from neuroscience. I wish to explore
the connections between a variety of educational, communication and psychotherapeutic
processes and try to show that constructivism holds the promise of providing some
unity to the practice of education and learning.
The constructivist model
The constructivist theory of learning, whose philosophical origins are frequently
ascribed to Kant and whose educational origins to Piaget, is based on the premise
that the act of learning is based on a process which connects new knowledge to pre-existing
knowledge. I do not intend to go into all the arguments surrounding this theory and
to describe the variety of constructivist models that have been created. The reader
is referred to the extensive literature on the subject.
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For the purposes of my argument it is simply necessary to acknowledge some basic
assumptions underpinning the theory from which important connections to other educational
theories can be made as well as to therapeutic practices, neuroscience and even the
nature of scientific knowledge.
Possibly the most well-known articulation of the underlying assumption of constructivism
is the famous quotation of Ausubel: “The most important factor influencing learning
is what the learner already knows”.
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In many years of teaching teachers how to teach I have found many people have an
intuitive grasp of this fact and tailor their teaching to take account of the background
knowledge of their students. Piaget expressed it differently by stressing that experience
is constantly being ‘assimilated’ or filtered through pre-existing concepts.
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New knowledge is therefore interpreted by existing knowledge and then connected
to existing knowledge. The implications of this conception are manifold and spread
beyond conventional education into interpersonal communication and psychotherapy.
In addition this phenomenon begs the question of how the process is conducted and
manifested in the brains of individuals.
The statement of Ausubel
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automatically leads to a pedagogical intervention even if it is merely ascertaining
the prior knowledge of a learner by asking questions. Piaget avoided suggesting detailed
pedagogy but certain ways of teaching flow from his assumptions. He stressed that
learning was fundamentally about interacting with the world in order to explore the
‘rules of the game’ and to discover the causal relationships between events. This
leads to an active pedagogy involving exploration, experience and experimentation.
Dewey aptly summarized this idea by saying that learners should be actors rather than
spectators.
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Others have extended this concept to suggest that individals interact with the world
in order to extract meaning from it and to construct a coherent and consistent cognitive
model. Another way of saying this is that our brains are programmed to support our
survival. From an evolutionary perspective organisms have evolved brains which create
and internalize an increasingly complex and accurate model of the world. Based on
our experience of interacting with the world we have each created our own unique model
of reality. Nevertheless we are social beings and we cannot ignore the power of social
interactivity that has influenced this process, a concept emphasised by the Russian
psychologist Vygotsky.
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Other human beings influence the way in which we construct our models giving rise
to the teacher and to the various social processes of pedagogy.
Model building in the individual, based on interactivity with the world, is the result
of a cognitive process which involves the experience of the world being assimilated
and filtered through prior knowledge as previously described. If sense or meaning
can be attached to the experience then the experience fits with existing cognitive
structures (Piaget’s ‘schemas’). However, if the experience does not make sense then
a feeling of dissatisfaction or cognitive dissonance can ensue in which the individual
will seek to reach some sort of mental equilibrium by exploration or questioning.
At this point the individual may make use of the faculty of imagination to suggest
or hypothesise why the experience is problematic. It is the existence of human imagination,
the ability of each of us to interrogate our mental model, to speculate and to ask
questions that is one of the hallmarks of our intelligence and our capacity to survive.
Albert Einstein famously stated that ‘imagination is more important than knowledge’
since he realized that ultimately all knowledge is derived from an initial process
of imagination that is subsequently tested against the world. As individuals we can
simulate reality by asking ourselves ‘what if?’ questions. We can perform acts in
our imagination before doing them in reality and risking having our genes deleted
from the gene pool.
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Our imagined conjectures can be tested by seeking other experiences and by so doing
we can resolve the dissonance and elaborate our learning and our mental model.
Constructivism and scientific reasoning
You may notice that what I have just described, as the individual attempts to construct
a more meaningful and coherent mental model, is what is often called hypothetico-deductive
reasoning. When confronted with experience hypotheses are created via inductive reasoning
and human imagination. These hypotheses are then tested by exploration, further experience
or deliberate manipulation of the world coupled to and processed by deductive reasoning.
Hypotheses are then either rejected or supported, leading to the elaboration of knowledge.
Hopefully the reader should now see that what the constructivist model of learning
describes in the individual is what is commonly known as the ‘scientific method’.
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Driver and many other constructivists have frequently asserted that the individual
learner behaves like a scientist in seeking to make sense of the world.
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Indeed Glopnik has gone so far as to assert that even the baby in the cradle is a
little scientist testing out hypotheses about reality.
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In summary we assert that the constructivist model is built on the premise that the
brain naturally attempts to extract meaning from the world by interpreting experience
through existing knowledge and then building and elaborating new knowledge in a process
identical to hypothetico-deductive reasoning or the scientific method.
Clinical diagnostic reasoning
Diagnostic reasoning is one of the key cognitive skills that doctors need to acquire
and medical schools need to teach. It has many characteristics in common with scientific
reasoning and hence is connected to the constructivist model. When a patient presents
with a problem the doctor will begin a process of hypothesis formation aided by information
derived from the patient’s history and examination findings. Pattern recognition and
‘gut feelings’ are important here but very much depend on the range and quality of
the mental models of illness presentation that they have built up. This initial phase
can be seen as an inductive process in which sensory information is assimilated through
the pre-existing knowledge of the clinician. The hypotheses, or differential diagnoses,
next require testing to see which ones can be supported, falsified and eliminated
by the acquisition of further evidence. This might involve more history taking and
examination or the ordering of investigations such as blood tests or radiographs.
The results obtained can be used to eliminate some hypotheses and can potentially
lead to a final diagnosis of the problem. This phase of the process is characterized
by deductive reasoning and the whole diagnostic process as hypothetico- deductive
reasoning, which can hopefully be seen as identical to the scientific method as previously
described.
Of course many things can go wrong in this process. Lack of background knowledge
and experience will inhibit the assimilative inductive phase and reduce hypothesis
formation from the imagination. Bias can influence the hypothesis testing phase by
only looking for evidence to support a diagnosis rather than attempting to falsify
one. Interpreting the results of investigations can also be influenced by a lack
of background knowledge and experience. There are a myriad factors that affect the
outcome of the diagnostic process and there are many ways of teaching this skill.
Nevertheless it is important from a medical education perspective that students are
made aware of the constructivist nature of the hypothetico-deductive process as the
underlying engine of diagnostic reasoning.
Now that the constructivist framework has been described and its relationship to scientific
method has been outlined it is useful to look at other theoretical models to see
if there are any connections that can be discerned.
Students’ theories
It is a remarkable and well evidenced observation that students learning science have
their own mental constructs or ‘theories’ and will articulate them when asked to explain
the phenomena they are exposed to.
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This can be explained by the constructivist model in that experiences will be filtered
through limited prior knowledge followed by imaginative attempts to provide a plausible
explanation. The student comes to school with years of personal experience of heat,
light, gravity, forces, motion, solids, liquids, gases, energy, electricity, plants,
animals and people. It is not surprising that strongly held theories about the nature
of the physical, biological and social world have been elaborated by the student even
before any scientific teaching is encountered.
Since the student is at the heart of learning good pedagogy suggests that it is essential
that teachers make the effort to try to understand the student’s point of view. Teachers
should create learning situations that encourage students to bring out their ideas.
It is here that the ‘social constructivist’ approaches described by Vygotsky become
important. The individual develops conceptual understanding via the social sharing
of meanings and intellectual debate. Thus as far as possible scientific and medical
learning should be a group activity with opportunities to discuss ideas, make hypotheses
and devise ways of testing them. The teacher should facilitate the developing conceptual
understanding of students by providing examples of cognitive conflict as well as emphasising
how well the ‘scientific’ concepts explain phenomena in comparison to the more contradictory
theories of the students. Of course the aim of teaching is to replace the ‘erroneous’
beliefs of the student with the ‘correct’ evidence-based scientific ones. Problem
based learning is an ideal way to create this teaching environment.
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However, children become adults and although they may then be considered mature thinkers
, (‘logical operators’ to use Piaget’s terminology), nevertheless it is clear from
many studies that they still have scientific misconceptions.
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Medical students can be considered to have broken through the immature phase of science
education and clearly they have successfully learned the correct scientific theories
and concepts required to get into medical school. Nevertheless, that doesn’t mean
they are immune from still having personal theories and erroneous beliefs that might
get in the way of acquiring the received evidence-based wisdom provided by their teachers.
Lay theories
Adults, with little knowledge of science and medicine beyond an elementary education,
will have ‘lay beliefs’ concerning the anatomy and physiology of the body and of the
causation of illness, and medical students and practitioners will interact with patients
holding such beliefs.
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Lay beliefs are therefore a component of the mental models that individuals have made
and hence are part of the constructivist framework. Health care professionals need
to be aware of lay theories when engaging with patients as they can have an important
impact on health outcomes.
However, when we move into the area of lay beliefs we are entering sociological territory
and the metaphor of construction is used in a radically different way. In Berger and
Luckman’s
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work ‘The Social Construction of Reality’ it is implied that reality itself is very
much a social construction and that there is no single, coherent, real world. This
‘Postmodern’ viewpoint asserts that individuals experience reality as multifaceted
and contradictory and rejects scientific ‘objectivity’. This extreme view of constructivism
can lead to a cognitive relativism that is a long way from the scientific approach.
Illness occurs within a culture that fundamentally shapes how that illness is experienced.
Anthropologists have provided a rich source of examples of the way in which lay beliefs
about illness are part of the social fabric of all societies. Many studies in contemporary
society demonstrate the continuing existence of a wide range of health beliefs that
are seen as causative factors in illness.
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It is tempting to suggest that these constellations of causal factors constitute
‘theoretical frameworks’ but they do not exhibit a high degree of consistency, order,
stability and rationality and respondents often maintain and use contradictory models
without recognising a logical inconsistency between them.
It may appear paradoxical that one of the claims of constructivism is that the brain
uses a process of ‘scientific’ enquiry to try to make sense of the world but that
individuals can then come up with and sustain ‘non-scientific’ beliefs or theories.
Although the process may follow a scientific logic the final outcomes can clearly
be totally unscientific and result from a lack of background knowledge, personal bias
and an uncritical interpretation of evidence. Thomas Kuhn famously proposed that even
scientists can be resistant to evidence that could lead to theory change and it sometimes
takes a revolution to enable ‘paradigm shifts’ to take place.
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Individuals can be equally resistant to evidence that might change their belief
systems and might need their own personal revolution.
Nevertheless the real and potential gulf between lay beliefs and medical knowledge
is a major factor in the therapeutic effectiveness of the doctor-patient relationship.
Doctors need to understand the constructions of their patients and need to speak to
them using language they can understand.
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Eliciting the patient’s ideas is an essential step in this process although this can
be another source of confusion since what a lay person understands by a particular
medical term maybe entirely different from the doctor’s understanding.
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In the medical field interpersonal communication or ‘communication skills’ is very
important. The ability to listen to an individual, to ask them questions, to interpret
what they are saying and to give them information and advice in a way that they can
understand is a major feature of good medical practice which in one sense is educational.
At the heart of it is an engagement with an individual that is analogous to the learner
centred approach and hence is described as patient centred. As in constructivist pedagogy
it involves finding out the background knowledge of the patient and then communicating
with them and educating them in a way that they can understand. If constructivist
pedagogy is used to establish prior knowledge it is also used in helping the patient
to construct their understanding of their condition and to help the doctor to establish
potentially new behaviours in the patient which will be of medical benefit. In many
ways this is fundamentally associated with a teaching process and the Cambridge-Calgary
method is a well established formulation of this method.
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Experiential learning
The experiential learning theory developed by David Kolb
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cites Piaget as a precursor in addition to acknowledging the influence of the social
factors on learning identified by Vygotsky. Therefore it comes with good constructivist
credentials. However, Kolb’s framework has been interpreted and misinterpreted by
so many individuals over the years that it is sometimes difficult to see where constructivist
concepts can be found within it. Because experiential or ‘non-formal’ learning frequently
happens in a haphazard and unstructured way, with individuals having raw experiences
in working environments, it is not always obvious that there is any pedagogy involved.
But those ‘concrete experiences’ still have to be assimilated through pre-existing
cognitive constructs. It is here that the social constructivist role of others becomes
important, either as mentors who deliberately foster ‘reflection’ or merely fellow
learners who can discuss and refine understanding. Kolb’s ‘abstract conceptualisations’
become the mental models discussed earlier and ‘active experimentation’ becomes the
deductive reasoning process associated with questioning and active learning.
Humanistic theories
In the field of education humanistic theories of learning have contributed ideas and
practices that complement constructivist and behaviourist models of learning. In
particular the humanistic theories of Rogers and Maslow emphasise the importance of
acknowledging the individual and starting from their standpoint in either a therapeutic
or educational process.
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This leads to human-centred or learner-centred approaches to education where the needs
of the learner become the heart of the educational process. In addition one of the
principles of adult learning, sometimes termed ‘andragogy’, is that the life experiences
and background knowledge of adult learners becomes an important educational resource.
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With adult learners, therefore, we build on and respect their prior knowledge, which
may have been acquired from their own personal needs. But as we have previously established
starting from where the learner is and building on their knowledge is a fundamental
tenet of the constructivist model. Thus we can establish a strong connection between
constructivism and learner-centred approaches.
Personal construct theory and cognitive behavioural therapy
George Kelly’s Personal Construct Theory
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is built on the premise that ‘all men are scientists’ and have constructed specific
mental constructs and beliefs based on their experiences that make them what they
are. It also posits that mistaken constructs can be created which can cause mental
problems and inappropriate behaviour. Constructivist psychotherapy and Cognitive Behavioural
Therapy are similarly based on the premise that individuals may have constructed inappropriate
behaviours and beliefs.
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Therapy involves challenging these ‘cognitive distortions’ to normalize behaviour.
Neuroscience
Social constructivists often stress that as social beings our knowledge is disseminated
amongst other human beings and also stored within physical locations such as libraries
and the internet. But we cannot lose sight of the fact that learning and memory are
ultimately processes that take place in individual human brains. Therefore what does
the constructivist metaphor mean in terms of neural structure and processing? Is the
construction of knowledge paralleled by the construction of neural structures and
do the pedagogical processes suggested by the epistemology of constructivism enhance
these constructions?
There is considerable evidence that our perceptions of reality and our own mental
states are, in fact, constructions. Images projected onto the retina are analysed
and processed by a variety of mechanisms in the brain and what we ‘think’ we see is
largely a creation of mental processing. The central image on the fovea, scanned
by unconsciously experienced saccadic eye movements, constitutes the centre of a perception
whose peripheral elements are entirely ‘filled in’ by the brain. We do not therefore
perceive reality as it actually is but we perceive a construct based on a probabilistic
model of reality created by the brain. Our brains are constantly predicting what is
out there in the world and by a series of ‘top down’ processes they fill in the sensory
data we are receiving to create what Clark has called a ‘controlled hallucination’.
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Further illustrations of how the brain constructs our perceptions, thoughts and even
feelings have been provided by the work of Ramachandran.
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,
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Oliver Sacks has also written eloquently about how individuals who have tragically
suffered from damage to specific regions of the brain can reconstruct their cognitions,
often in strange and unusual ways.
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The key conception that derives from these studies and observations is that the brain
actively ‘fills in’ gaps in perception, sensation and cognition with constructs that
attempt to maintain some sort of mental cohesion, even if the results can sometimes
be anomalous.
It has been argued that constructivism is underpinned by mainstream theories of cognitive
neuroscience: it is how our brains work when we are learning. According to Quartz
and Sejnowski
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the cerebral cortex has evolved to maximize its structure and function through constructive
learning. In addition the importance of active learning methods, as recommended by
constructivist pedagogy, is supported by studies of neurogenesis in the adult brain.
Neurogenesis continually occurs in the dentate gyrus area of the hippocampus of the
human brain, a region well known for its part in learning and memory.
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Furthermore it is now established from mouse models that activity in an enriched living
environment stimulates neurogenesis and results in increased synaptic connectivity.
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The implication of these and other studies suggests that learning is a physically
constructive process in the brain which is enhanced by active learning.
Conclusions
The key principle of constructivism in education is that learning is always a building
process whereby new knowledge can only be added on to and understood in terms of
existing knowledge. The ramifications of this concept are significant. Constructivist
epistemology suggests constructivist pedagogy such as always checking and activating
prior learning. Constructivism implies that hypothetico-deductive reasoning is a process
we all engage in when trying to understand the world. The scientific method and diagnostic
reasoning are essentially constructivist. Constructivism underpins many human interactions
where dealing with and recognising the prior knowledge and personal constructs of
an individual are important such as teaching in general, communication skills in medicine
and some types of psychotherapy. Finally it is increasingly being suggested that the
physical structure of the brain and its processes provides a neuroscientific rationale
for constructivist cognition implying that certain pedagogical methods such as active
learning should be encouraged. All medical and health science educators should be
aware of the fundamental principles of constructivism and the extent of its influence
on educational theory and clinical practice.
Conflicts of Interest
The author declares that he has no conflict of interest.