Constructivism: reflections on twenty five years teaching the constructivist approach in medical education

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.1-6    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”.7 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.8    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 Ausubel7 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.9 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.10 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.11 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.