International Journal of Medical Education.

2016;7:200-205 Perspectives
ISSN: 2042-6372
DOI: 10.5116/ijme.5763.de11

Constructivism: reflections on twenty five years

Medical Education Unit, School of Medicine, University of Nottingham, UK

Correspondence: Prof. Reg Dennick, Medical Education Unit , School of Medicine, University of Nottingham, Nottingham, NG7 2UH,
UK. Email: reg.dennick@nottingham.ac.uk

Accepted: June 17, 2016

Introduction
There is no single overarching theoretical framework that necessary to acknowledge some basic assumptions
accounts for how we learn in all situations. There are many underpinning the theory from which important
theories of how we learn from our experiences and there are connections to other educational theories can be made as
many theories of what experiences are. We know that we well as to therapeutic practices, neuroscience and even the
do learn and that we have knowledge but there is no con- nature of scientific knowledge.
sensus on the relationship between the mechanism by Possibly the most well-known articulation of the under-
which our brains learn and the optimal way in which we lying assumption of constructivism is the famous quotation
should be taught. In other words there is no necessary of Ausubel: “The most important factor influencing learn-
connection between epistemology and pedagogy. We seem ing is what the learner already knows”.7 In many years of
capable of learning from a wide variety of pedagogical teaching teachers how to teach I have found many people
processes and although there is empirical evidence that have an intuitive grasp of this fact and tailor their teaching
some ways of learning are more effective than others in to take account of the background knowledge of their
specific situations no one pedagogical method dominates. students. Piaget expressed it differently by stressing that
However, reflecting on twenty five years as a medical experience is constantly being ‘assimilated’ or filtered
educationalist I have come to the conclusion that there is through pre-existing concepts.8 New knowledge is there-
one framework that makes more connections between fore interpreted by existing knowledge and then connected
different epistemological and pedagogical theories than to existing knowledge. The implications of this conception
others and that could have support from neuroscience. I are manifold and spread beyond conventional education
wish to explore the connections between a variety of into interpersonal communication and psychotherapy. In
educational, communication and psychotherapeutic addition this phenomenon begs the question of how the
processes and try to show that constructivism holds the process is conducted and manifested in the brains of
promise of providing some unity to the practice of individuals.
education and learning. The statement of Ausubel7 automatically leads to a ped-
agogical intervention even if it is merely ascertaining the
The constructivist model prior knowledge of a learner by asking questions. Piaget
The constructivist theory of learning, whose philosophical avoided suggesting detailed pedagogy but certain ways of
origins are frequently ascribed to Kant and whose educa- teaching flow from his assumptions. He stressed that
tional origins to Piaget, is based on the premise that the act learning was fundamentally about interacting with the
of learning is based on a process which connects new world in order to explore the ‘rules of the game’ and to
knowledge to pre-existing knowledge. I do not intend to go discover the causal relationships between events. This leads
into all the arguments surrounding this theory and to to an active pedagogy involving exploration, experience and
describe the variety of constructivist models that have been experimentation. Dewey aptly summarized this idea by
created. The reader is referred to the extensive literature on saying that learners should be actors rather than spectators.9
the subject.1-6 For the purposes of my argument it is simply Others have extended this concept to suggest that

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© 2016 Reg Dennick. This is an Open Access article distributed under the terms of the Creative Commons Attribution License which permits unrestricted use of work
provided the original work is properly cited. http://creativecommons.org/licenses/by/3.0
individals interact with the world in order to extract learning describes in the individual is what is commonly
meaning from it and to construct a coherent and consistent known as the ‘scientific method’.12 Driver and many other
cognitive model. Another way of saying this is that our constructivists have frequently asserted that the individual
brains are programmed to support our survival. From an learner behaves like a scientist in seeking to make sense of
evolutionary perspective organisms have evolved brains the world. 13 Indeed Glopnik has gone so far as to assert
which create and internalize an increasingly complex and that even the baby in the cradle is a little scientist testing out
accurate model of the world. Based on our experience of hypotheses about reality.14
interacting with the world we have each created our own In summary we assert that the constructivist model is
unique model of reality. Nevertheless we are social beings built on the premise that the brain naturally attempts to
and we cannot ignore the power of social interactivity that extract meaning from the world by interpreting experience
has influenced this process, a concept emphasised by the through existing knowledge and then building and elaborat-
Russian psychologist Vygotsky.10 Other human beings ing new knowledge in a process identical to hypothetico-
influence the way in which we construct our models giving deductive reasoning or the scientific method.
rise to the teacher and to the various social processes of
Clinical diagnostic reasoning
pedagogy.
Model building in the individual, based on interactivity Diagnostic reasoning is one of the key cognitive skills that
with the world, is the result of a cognitive process which doctors need to acquire and medical schools need to teach.
involves the experience of the world being assimilated and It has many characteristics in common with scientific
filtered through prior knowledge as previously described. If reasoning and hence is connected to the constructivist
sense or meaning can be attached to the experience then the model. When a patient presents with a problem the doctor
experience fits with existing cognitive structures (Piaget’s will begin a process of hypothesis formation aided by
‘schemas’). However, if the experience does not make sense information derived from the patient’s history and exami-
then a feeling of dissatisfaction or cognitive dissonance can nation findings. Pattern recognition and ‘gut feelings’ are
ensue in which the individual will seek to reach some sort of important here but very much depend on the range and
mental equilibrium by exploration or questioning. At this quality of the mental models of illness presentation that
point the individual may make use of the faculty of imagi- they have built up. This initial phase can be seen as an
nation to suggest or hypothesise why the experience is inductive process in which sensory information is assimilat-
problematic. It is the existence of human imagination, the ed through the pre-existing knowledge of the clinician. The
ability of each of us to interrogate our mental model, to hypotheses, or differential diagnoses, next require testing to
speculate and to ask questions that is one of the hallmarks see which ones can be supported, falsified and eliminated
of our intelligence and our capacity to survive. Albert by the acquisition of further evidence. This might involve
Einstein famously stated that ‘imagination is more im- more history taking and examination or the ordering of
portant than knowledge’ since he realized that ultimately all investigations such as blood tests or radiographs. The
knowledge is derived from an initial process of imagination results obtained can be used to eliminate some hypotheses
that is subsequently tested against the world. As individuals and can potentially lead to a final diagnosis of the problem.
we can simulate reality by asking ourselves ‘what if?’ ques- This phase of the process is characterized by deductive
tions. We can perform acts in our imagination before doing reasoning and the whole diagnostic process as hypothetico-
them in reality and risking having our genes deleted from deductive reasoning, which can hopefully be seen as
the gene pool.11 Our imagined conjectures can be tested by identical to the scientific method as previously described.
seeking other experiences and by so doing we can resolve Of course many things can go wrong in this process.
the dissonance and elaborate our learning and our mental Lack of background knowledge and experience will inhibit
model. the assimilative inductive phase and reduce hypothesis
formation from the imagination. Bias can influence the
Constructivism and scientific reasoning hypothesis testing phase by only looking for evidence to
You may notice that what I have just described, as the support a diagnosis rather than attempting to falsify one.
individual attempts to construct a more meaningful and Interpreting the results of investigations can also be influ-
coherent mental model, is what is often called hypothetico- enced by a lack of background knowledge and experience.
deductive reasoning. When confronted with experience There are a myriad factors that affect the outcome of the
hypotheses are created via inductive reasoning and human diagnostic process and there are many ways of teaching this
imagination. These hypotheses are then tested by explora- skill. Nevertheless it is important from a medical education
tion, further experience or deliberate manipulation of the perspective that students are made aware of the constructiv-
world coupled to and processed by deductive reasoning. ist nature of the hypothetico-deductive process as the
Hypotheses are then either rejected or supported, leading underlying engine of diagnostic reasoning.
to the elaboration of knowledge. Hopefully the reader Now that the constructivist framework has been de-
should now see that what the constructivist model of scribed and its relationship to scientific method has been

Int J Med Educ. 2016; 7:200-205 201

outlined it is useful to look at other theoretical models to see the causation of illness, and medical students and practi-
if there are any connections that can be discerned. tioners will interact with patients holding such beliefs.18-21
Lay beliefs are therefore a component of the mental models
Students’ theories
that individuals have made and hence are part of the
It is a remarkable and well evidenced observation that constructivist framework. Health care professionals need to
students learning science have their own mental constructs be aware of lay theories when engaging with patients as they
or ‘theories’ and will articulate them when asked to explain can have an important impact on health outcomes.
the phenomena they are exposed to.15 This can be explained However, when we move into the area of lay beliefs we
by the constructivist model in that experiences will be are entering sociological territory and the metaphor of
filtered through limited prior knowledge followed by construction is used in a radically different way. In Berger
imaginative attempts to provide a plausible explanation. and Luckman’s22 work ‘The Social Construction of Reality’
The student comes to school with years of personal experi- it is implied that reality itself is very much a social construc-
ence of heat, light, gravity, forces, motion, solids, liquids, tion and that there is no single, coherent, real world. This
gases, energy, electricity, plants, animals and people. It is ‘Postmodern’ viewpoint asserts that individuals experience
not surprising that strongly held theories about the nature reality as multifaceted and contradictory and rejects scien-
of the physical, biological and social world have been tific ‘objectivity’. This extreme view of constructivism can
elaborated by the student even before any scientific teaching lead to a cognitive relativism that is a long way from the
is encountered. scientific approach.
Since the student is at the heart of learning good peda-
Illness occurs within a culture that fundamentally
gogy suggests that it is essential that teachers make the
shapes how that illness is experienced. Anthropologists have
effort to try to understand the student’s point of view.
provided a rich source of examples of the way in which lay
Teachers should create learning situations that encourage
beliefs about illness are part of the social fabric of all socie-
students to bring out their ideas. It is here that the ‘social
ties. Many studies in contemporary society demonstrate the
constructivist’ approaches described by Vygotsky become
continuing existence of a wide range of health beliefs that
important. The individual develops conceptual understand-
are seen as causative factors in illness.23 It is tempting to
ing via the social sharing of meanings and intellectual
suggest that these constellations of causal factors constitute
debate. Thus as far as possible scientific and medical learn-
‘theoretical frameworks’ but they do not exhibit a high
ing should be a group activity with opportunities to discuss
degree of consistency, order, stability and rationality and
ideas, make hypotheses and devise ways of testing them.
respondents often maintain and use contradictory models
The teacher should facilitate the developing conceptual
without recognising a logical inconsistency between them.
understanding of students by providing examples of cogni-
It may appear paradoxical that one of the claims of con-
tive conflict as well as emphasising how well the ‘scientific’
structivism is that the brain uses a process of ‘scientific’
concepts explain phenomena in comparison to the more
enquiry to try to make sense of the world but that individu-
contradictory theories of the students. Of course the aim of
als can then come up with and sustain ‘non-scientific’
teaching is to replace the ‘erroneous’ beliefs of the student
beliefs or theories. Although the process may follow a
with the ‘correct’ evidence-based scientific ones. Problem
scientific logic the final outcomes can clearly be totally
based learning is an ideal way to create this teaching
unscientific and result from a lack of background
environment.16
knowledge, personal bias and an uncritical interpretation of
However, children become adults and although they
evidence. Thomas Kuhn famously proposed that even
may then be considered mature thinkers , (‘logical opera-
scientists can be resistant to evidence that could lead to
tors’ to use Piaget’s terminology), nevertheless it is clear
theory change and it sometimes takes a revolution to enable
from many studies that they still have scientific misconcep-
‘paradigm shifts’ to take place.24 Individuals can be equally
tions.17 Medical students can be considered to have broken
resistant to evidence that might change their belief systems
through the immature phase of science education and
and might need their own personal revolution.
clearly they have successfully learned the correct scientific
theories and concepts required to get into medical school. Nevertheless the real and potential gulf between lay be-
Nevertheless, that doesn’t mean they are immune from still liefs and medical knowledge is a major factor in the thera-
having personal theories and erroneous beliefs that might peutic effectiveness of the doctor-patient relationship.
get in the way of acquiring the received evidence-based Doctors need to understand the constructions of their
wisdom provided by their teachers. patients and need to speak to them using language they can
understand.25 Eliciting the patient’s ideas is an essential step
Lay theories in this process although this can be another source of
Adults, with little knowledge of science and medicine confusion since what a lay person understands by a particu-
beyond an elementary education, will have ‘lay beliefs’ lar medical term maybe entirely different from the doctor’s
concerning the anatomy and physiology of the body and of understanding.26

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In the medical field interpersonal communication or ground knowledge of adult learners becomes an important
‘communication skills’ is very important. The ability to educational resource.31 With adult learners, therefore, we
listen to an individual, to ask them questions, to interpret build on and respect their prior knowledge, which may
what they are saying and to give them information and have been acquired from their own personal needs. But as
advice in a way that they can understand is a major feature we have previously established starting from where the
of good medical practice which in one sense is educational. learner is and building on their knowledge is a fundamental
At the heart of it is an engagement with an individual that tenet of the constructivist model. Thus we can establish a
is analogous to the learner centred approach and hence is strong connection between constructivism and learner-
described as patient centred. As in constructivist pedagogy centred approaches.
it involves finding out the background knowledge of the
Personal construct theory and cognitive behavioural
patient and then communicating with them and educating
them in a way that they can understand. If constructivist therapy
pedagogy is used to establish prior knowledge it is also used George Kelly’s Personal Construct Theory32 is built on the
in helping the patient to construct their understanding of premise that ‘all men are scientists’ and have constructed
their condition and to help the doctor to establish potential- specific mental constructs and beliefs based on their experi-
ly new behaviours in the patient which will be of medical ences that make them what they are. It also posits that
benefit. In many ways this is fundamentally associated with mistaken constructs can be created which can cause mental
a teaching process and the Cambridge-Calgary method is a problems and inappropriate behaviour. Constructivist
well established formulation of this method.27 psychotherapy and Cognitive Behavioural Therapy are
similarly based on the premise that individuals may have
Experiential learning constructed inappropriate behaviours and beliefs.33 Therapy
The experiential learning theory developed by David Kolb28 involves challenging these ‘cognitive distortions’ to normal-
cites Piaget as a precursor in addition to acknowledging the ize behaviour.
influence of the social factors on learning identified by
Vygotsky. Therefore it comes with good constructivist Neuroscience
credentials. However, Kolb’s framework has been inter- Social constructivists often stress that as social beings our
preted and misinterpreted by so many individuals over the knowledge is disseminated amongst other human beings
years that it is sometimes difficult to see where constructiv- and also stored within physical locations such as libraries
ist concepts can be found within it. Because experiential or and the internet. But we cannot lose sight of the fact that
‘non-formal’ learning frequently happens in a haphazard learning and memory are ultimately processes that take
and unstructured way, with individuals having raw experi- place in individual human brains. Therefore what does the
ences in working environments, it is not always obvious constructivist metaphor mean in terms of neural structure
that there is any pedagogy involved. But those ‘concrete and processing? Is the construction of knowledge paralleled
experiences’ still have to be assimilated through pre-existing by the construction of neural structures and do the peda-
cognitive constructs. It is here that the social constructivist gogical processes suggested by the epistemology of con-
role of others becomes important, either as mentors who structivism enhance these constructions?
deliberately foster ‘reflection’ or merely fellow learners who There is considerable evidence that our perceptions of
can discuss and refine understanding. Kolb’s ‘abstract reality and our own mental states are, in fact, construc-
conceptualisations’ become the mental models discussed tions. Images projected onto the retina are analysed and
earlier and ‘active experimentation’ becomes the deductive processed by a variety of mechanisms in the brain and what
reasoning process associated with questioning and active we ‘think’ we see is largely a creation of mental processing.
learning. The central image on the fovea, scanned by unconsciously
experienced saccadic eye movements, constitutes the centre
Humanistic theories of a perception whose peripheral elements are entirely ‘filled
In the field of education humanistic theories of learning in’ by the brain. We do not therefore perceive reality as it
have contributed ideas and practices that complement actually is but we perceive a construct based on a probabil-
constructivist and behaviourist models of learning. In istic model of reality created by the brain. Our brains are
particular the humanistic theories of Rogers and Maslow constantly predicting what is out there in the world and by a
emphasise the importance of acknowledging the individual series of ‘top down’ processes they fill in the sensory data we
and starting from their standpoint in either a therapeutic or are receiving to create what Clark has called a ‘controlled
educational process.29,30 This leads to human-centred or hallucination’.34
learner-centred approaches to education where the needs of Further illustrations of how the brain constructs our
the learner become the heart of the educational process. In perceptions, thoughts and even feelings have been provided
addition one of the principles of adult learning, sometimes by the work of Ramachandran.35,36 Oliver Sacks has also
termed ‘andragogy’, is that the life experiences and back written eloquently about how individuals who have

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