How Time, Narrative, and Discomfort Shape Learning: A Realist Evaluation of Behavioral Science Education for Medical Students

Junji Haruta; Toshiaki Kikuchi; Junko Kitanaka; Makoto Kurata

doi:10.5334/pme.2332

How Time, Narrative, and Discomfort Shape Learning: A Realist Evaluation of Behavioral Science Education for Medical Students

Perspectives on Medical Education

Volume 15 (2026): Issue 1

By: Junji Haruta , Toshiaki Kikuchi, Junko Kitanaka and Makoto Kurata

Open Access

|May 2026

Abstract

Introduction: Medical students are increasingly expected to navigate uncertainty, emotional complexity, and value conflicts, yet little is known about how behavioral science education fostered these capacities. This study aimed to identify the mechanisms through which a third-year behavioral science course influenced students’ cognitive, emotional, and relational development.

Methods: We conducted a realist evaluation of a course that integrated structured (Cognitive Behavioral Therapy; CBT)-based reflection, narrative immersion using complex clinical cases, and conceptual framing from the humanities and social sciences. Slow Education served as a sensitizing concept in developing initial program theories. Data were drawn from written reflections, group discussions, classroom observations, and field notes from two cohorts of students (N = 210). Abductive and retroductive coding strategies were used to refine context–mechanism–outcome (CMO) configurations.

Results: We identified five learning mechanisms: (1) emotional articulation that enabled readiness for deeper engagement; (2) narrative destabilization of biomedical certainty; (3) positional reframing supported by structured questioning; (4) epistemic disruption that fostered tolerance for ambiguity; and (5) conceptual reframing that legitimized discomfort and supported meaning-making. These mechanisms operated sequentially, forming a cumulative learning pathway. A certainty-seeking response functioned as a competing mechanism for some students, leaving intended mechanisms unactivated under particular contextual conditions.

Discussion: The findings demonstrated how behavioral science education activated interconnected mechanisms that supported students’ development of reflective capacity, perspective-taking, and tolerance for ambiguity. The resulting middle-range explanation clarifies why structured emotional work, narrative complexity, guided questioning, and conceptual scaffolding enabled deeper engagement with the psychosocial dimensions of clinical practice.

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Articles in this issue

DOI: https://doi.org/10.5334/pme.2332 | Journal eISSN: 2212-277X

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Language: English

Page range: 397 - 409

Submitted on: Dec 6, 2025

Accepted on: Mar 6, 2026

Published on: May 5, 2026

Published by: Ubiquity Press

In partnership with: Paradigm Publishing Services

Publication frequency: 1 issue per year

© 2026 Junji Haruta, Toshiaki Kikuchi, Junko Kitanaka, Makoto Kurata, published by Ubiquity Press
This work is licensed under the Creative Commons Attribution 4.0 License.

Volume 15 (2026): Issue 1