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1  DOI: https://doi.org/10.47391/JPMA.830
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Is behaviourism really dead? a scoping review to document the

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4  presence of behaviourism in current medical education
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Ambreen Ansar1, Aisha Rafi2, Robina Mushtaq Rizvi3

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1,3 Department of Community Medicine, Wah Medical College, Wah Cantt, Rawalpindi,

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8  Pakistan; 2 Department of Anatomy, Shifa College of Medicine, Shifa Tameer E Millat

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9  University, Rawalpindi, Pakistan.
10  Correspondence: Ambreen Ansar. Email: ansarambreen@gmail.com

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12  Abstract ed
13  Behaviourism is the underpinning learning theory of many teaching and
14  assessment tools utilised to enhance the effectiveness of learning. Feedback,
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15  reinforcements, motivation, learning outcomes and objectives are a few among
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16  many which are implied by the medical teachers while teaching both basic and
17  clinical sciences to students. The claim of behaviourism being redundant or
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18  dead is not based on realities. The behaviourist approach is and will remain the
19  most powerful theory to be implied in educational processes for gaining
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20  successful outcomes.

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21  Key Words: Behaviourism, Implications, Medical education, Dead, Learning.

22 
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23  Introduction
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24  Although a lot of evidence exists regarding the use of behaviourst approach
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25  (BA) in teaching and learning (T&L) but the weight of evidence fall towards its
26  extinction as a practical approach(1). In contrast to what most of the literature
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27  says, a lot of behaviourist-based T&L approaches still exist and are in fact very
28  beneficial. The foremost underlying reasons for calling BA dead or abandoned
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29  seems to be a blind following of zeitgeist, and an incomplete understanding of

30  BA which includes a lot of varieties, like methodological, radical, analytical and
31  psychological behaviourism etc(2). These reasons, along with the contemporary

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32  rise of other educational paradigms, led to the downfall of BA in literature. But

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33  for all practical purposes, BA remained steadfast and the most basic

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34  assumptions of all the theories of BA i.e. stimulus leads to a response which can

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35  be conditioned and altered by appropriate reinforcement, remains the mainstay

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36  of all instructional designs(3). Further information had been added between these

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37  two points, and the reinforcement, rewards and punishments might have been
38  given different names or definitions, but the start and the end remain the same
39  for all effective T&L sessions.

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40  The current narrative review was planned to find the literature available on
41  behaviourist theories using the scoping review methodology to prove the
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42  existence of BA as a living and practical approach towards T&L, and to see
what modifications have been made in original theories of Behaviourism, to
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44  address the modern learners’ needs, which so many educationists failed to grasp
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45  or express in their writings. The findings are expected to inform the faculty
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46  about its usefulness in certain contexts and situations where other approaches
47  fail to work. The aim of the review was not to find who is right or wrong, but to
stress the need for the multidimensionality of the education to be addressed with
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49  multidimensional approaches to make it completely holistic, meaningful and

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50  fruitful.
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51 

52  Methodology
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53  The steps of Arksey & O’Malley(4) were followed in the current scoping review.
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54  A detailed flow chart was subsequently followed (Figure 1) with specific key
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55  words (Table 1).

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57 
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58  Results
59  Of the total, 5(22.7%) publications appeared in literature before year 2000,
60  5(22.7%) between 2000 and 2010, and 12(54.5%) were published between 2011

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61  and 2018.

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62  Of the total, 12(57%) publications related to the United States (Figure 2).

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63  Of all the publications, 17(76.2%) were original articles (Figure 3).

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64  All the publications finally selected were studied thrice and the information was

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65  sorted into two potential themes (Table 2).

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66  The ideas derived from Behaviourism used in medical education were grouped
67  and tabulated under various headings using an Excel sheet. The frequency of
68  each theme derived from Behaviourism was noted (Table 3).

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69 

70  Discussion
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71  The publications identified included 19(90.4%) articles which discussed the
basics of Behaviourism and responded to the critique on Behaviourism. There
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73  were 16 (76.2%) articles in which implications of BA in medical education were

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74  discussed. This short review may not be exhaustive, but it will attempt to give
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75  an overview of BA, and to answer the critiques on BA, mainly by Robbie et al.
(5)
76  , under the headings of identified themes.
The goals of medical education are to produce a medical expert, a clinician, a
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78  researcher, a problem-solver, a leader and a manager. In addition to these goals,

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79  other versatilities that needed to be dealt with include personal and cultural
diversity of the students. All the students do not have the same kind of training
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81  and background knowledge. This warrants the use of various T&L methods that
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82  are wide enough to accommodate all these diversities.

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83  The most doable dynamics of learning are presented by the behaviourist
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84  philosophy of education. Although other philosophies have gained attention of

85  today’s educationists, behaviourist’s simple, frugal and parsimonious
86  characteristics still make it viable and practical in today’s educational field.
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87  Basic Assumptions of Behaviourism: Over the past two to three decades there
88  is a detrimental decrease in the number of publications focused on BA in
89  educational psychology(6). This decline is reciprocally related to the rise in other

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90  educational philosophies, including cognitivism, constructivism and humanism.

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91  Educational programmes based on BA gained a lot of publicity in the 1960-80

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92  period. But by the end of the 1980s the research on behaviourism as an

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93  educational approach was minimal and those who mentioned it in their papers

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94  called it “dead” or abandoned(5-7). This review aimed at revitalising this area of

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95  educational philosophy.
96  Behaviourism postulates that all behaviour is learned from the environment and
97  it is observable. Learning has occurred only if one can see a change in a

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98  person’s behaviour. The starting point of learning is stimulus, leading to
99  response, and a consequence. If the consequence is satisfying, the response will
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100  be learned and strengthened, otherwise the person will respond to the stimulus
in some other way until it becomes rewarding. This is called operant
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102  conditioning. The classical conditioning is stimulus leading to a response

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103  wherein the stimulus and the response can be conditioned. This classical
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104  conditioning, therefore, suggests that even the physiological responses can be
105  altered by using the behaviourist technique. The third theory of Trial & Error
communicates the active role of the learner in problem-solving which has not
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107  been tackled or seen before. In all these theories, reinforcement acts as a catalyst
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108  which promotes or demotes a behaviour or response carried out by the learner,
depending upon whether it is positive or negative(7). One other mode of BA is
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110  modelling or learning by observation. This vicarious learning theory of

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111  behaviourism demonstrates the importance of the social environment in the

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112  process of learning(8,9).

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113  Types of Behaviourism: Behaviourism has many variations among which two
114  are more outstanding than others, namely; methodological behaviourism (MB)
115  and radical behaviourism (RB)(10). Literature search unfolds that the major
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116  critique on behaviourism is due to the confusion created by the researchers who
117  took both varieties as one, and did not take into account the advances or
118  modifications carried out by Skinner(11). He neither considered the learners as

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119  “tabula rasa” nor as a passive recipient of the knowledge. He believed that

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120  learners are born with innate behaviours which help them to learn things in their

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121  own way. The experiments conducted by Skinner & Thorndike clearly indicated

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122  a highly active role of the learner in the learning process, like solving the puzzle

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123  in a puzzle box or finding the rule of pressing the lever to gain the advantage.

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124  He also recognised the role of “private events” in learning (11).
125  Role of Reinforcement: Researchers criticise that reinforcement used by the
126  behaviourists were not proven as powerful as claimed by them. The

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127  reinforcement techniques are applied only to “how” of learning and it does not
128  help in deciding the “what” (5). This objection seems to be invalid as the “what”
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129  and “how” of learning are two entirely different aspects, and need to be
addressed differently. What these researchers fail to understand here is how a
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131  procedural solution can deal with the structural problem. Another exposition on
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132  BA is that it cannot be applied without reinforcement(5). Reinforcement might

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133  change its forms, but, in whatever form available, it is strongly recommended
134  by all the educationists and researchers of past and present (12)(13)(14)(15)(16).
They also suggest that the focus of learning should shift from reinforcement to
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136  the systematic building of skills(17). But this objection raises the questions if the
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137  change of focus from reinforcement to skill reduces its importance. Can the skill
replace reinforcement? Or can the skill be taught without using reinforcement?
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139  The effective T&L and building of higher order skills can only be provided if
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140  continuous reinforcement is provided. No learning can take place without some
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141  kind of reinforcement reaching the learner and it lies at the heart of every
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142  learning endeavour. It may be provided by the teacher, facilitator, colleague,

143  peer, student or the environment. Someone or something is always there to
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144  “push” the learner either in favour of or against learning, and tell them what is
145  correctly learned and what is incorrect. That “push” is the reinforcement.
146  The validity of Behavioural Learning Objectives: Another weakness of BA,

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147  as pointed out by the researchers, is stated as “an awkward, almost useless

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148  language for specifying objectives”(5). This, again, is an unreasonable objection.

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149  Deciding Learning Objectives (LO), which are specific, measurable, achievable,

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150  relevant/realistic and time-bound, is the most important task while designing a

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151  curriculum. Without the knowledge of destination, how can one decide the

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152  routes and resources? There is abundant evidence proving the high relevance of
153  making behaviourally-oriented objectives which are easy to assess and
(18)(19)(16)(20)(21)(11)(22)
154  communicate to the stakeholders . Robbie et al. here are

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155  perplexed about the achievement of objectives related to the understanding of
156  the concepts. They think that to achieve the LO of understanding, the learner
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157  has either to turn down to rote memorisation or to move up to the application of
the concept. In both cases, the LO of understanding, in their opinion, could not
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159  be achieved. This complaint has been removed by Bloom in his works on an
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160  explanation of six levels of cognition(23).

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161  It can also be said that the “how” of defining enabling objectives should have
162  been told by the behaviourists. This opposition claim is very weak and is
answered by themselves in the same paragraph when they say that the
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164  educationists have to use their own intellect and expertise to design the smaller
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165  steps required to attain the main target. It is so because in all the fields every
content which needs to be taught to the students has different requisites to be
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167  understood and applied by the learners depending upon its complexity and
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168  difficulty level. The person designing the LO and the curriculum should be a
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169  content expert along with an educationist to decide the size of the steps or the
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170  amount of the content to be delivered in a single encounter.

171  Instructional Design and Behaviourism: In the same article, the claim of
172  Robbie et al. that BA has proven irrelevant in instructional design (ID) is also
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173  very inapt. BA is the basis for providing the foundations to almost all the ID
174  used in today’s education, including the online learning programmes. The basis
175  comes from Skinner’s operant conditioning, Watson’s learning theories and

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176  Bandura’s social learning theory (13)(22)(24)(25).

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177  Cognitive processes and Behaviourism

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178  The critics of BA and those describing the transition from BA to cognitivist

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179  approach put a lot of stress on cognitive processes occurring while learning, and

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180  de-emphasise the role of reinforcement and disapprove BA’s emphasis on

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181  observable behaviours and end-tasks(5). Does this disparagement really nullify
182  the importance of achieving “desired behaviours” and reinforcement role in
183  favour of learning? It will be bizarre to think in this manner as the “desired

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184  behaviours” at the end of any T&L session is all that is desired. If the focus
185  truly shifts away from the observable and desired behaviours to the complex
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186  mental processes, no mastery can be gained in a limited amount of time we
usually have. Understanding the cognitive processes may help in understanding
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188  how the learning is occurring and how it can be made more efficient, but
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189  leaving behind the LOs and thus the assessments will cause many learners to
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190  wander away and lose precious time. The mainstay of discussing this point is
191  that the relative importance of some concepts might increase or decrease with
more research, but the main constructs proposed by behaviourists are
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193  irreplaceable.
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194  One of the other main criticisms and misunderstanding on BA is that they
discard the role of cognitive or mental processes in the learning process. Skinner
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196  extended behaviourism and coined the term RB for his prepositions in which he
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197  accounted the private events including thinking and feelings as a genuine matter
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198  to be studied and experimented(6)(26)(10)(27). Thus it is once again emphasised that

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199  one should keep in view the conflicting varieties of behaviourism before getting
200  too sceptical on the approach. It would be fallacious to sweep all behaviourism
201  with one wand.
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202  Problem-solving and Behaviourism

203  One of the articles argues that the learners trained via BA will not become
204  creative and problem-solvers and their critical thinking ability might be

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205  compromised(28). But here, again, it is argued that if a child at its initial learning

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206  stage is not taught the alphabets, would he be able to create all of them in the

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207  same manner as they exist now? The logical answer should be “no”. But if

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208  someone says “yes’ and hopes that the child would be both intelligent and lucky

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209  enough to create all the alphabets, how long would it take? Is it wise to waste

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210  his precious time in discovering the things already known and proven correct,
211  useful and practical beyond doubt? If some researchers still think that the child
212  should be given open hand and the teacher should not teach him anything so

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213  that he could go to the voyage of discovery learning, will the language he create
214  will be understandable and acceptable to all others? Creativity and problem-
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215  solving should start after the ABCs of the field have been taught to the student
which need the laws of BA to be applied in T&L. They should have a good
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217  amount of prior knowledge in their heads before embarking upon the journey of
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218  problem-solving and creativity. All theories are best, including behaviourism, if
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219  applied in the correct perspective.

220  Questions for Cognitivist
At this point it might be interesting to ask the proponents of cognitive
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222  revolution, who say that behaviourism is dead or abandoned, that how learning
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223  used to occur when these events were unknown; what were the starting and
finishing points of any learning activity? The learning process can be defined
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225  using BA alone, but cannot be defined by using the cognitivist approach alone.
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226  They would ultimately have to borrow something from BA in order to make
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227  their points clear. BA provides a complete structural overview of the learning
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228  process, while cognitivism adds to the story by explaining in little more detail of
229  what happens when a learner moves from preliminary behaviours to the desired
230  behaviours.
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231  Can We Manage Classrooms And Institutions Without Behaviourism?

232  James in 1978 spoke in favour of behaviourism when the so-called cognitive
233  revolution was on the rise and the researchers were generally becoming

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234  opponents of behaviourism (12). He and many others recognised the use of BA in

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235  classroom and school management as a necessary approach because all the

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236  teachers and faculty are answerable to higher authorities, parents of the students,

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237  and society at large. This accountability leaves little room for the purely

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238  inquiry-based learning approaches to be adopted in medical education and

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239  warrants the use of BA to achieve the stated objectives. The rules of attendance,
240  uniforms, minimum competency-based curriculum, drill and practice of the
241  mandatory skills, assessments and grades are all examples of applications and

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242  connotations of BA in medical education.
243  Other Implications Derived from BA
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244  Several practical applications of the laws of learning have been derived from
BA. These include motivation and appropriate prior knowledge from the law of
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246  readiness, repetition and practice time for learning a skill from the law of
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247  exercise, conditioning of study behaviour and dealing with anxiety from the law
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248  of operant conditioning(28).

249 
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250  Conclusion
251  BA, despite stumbling upon a lot of critique, shortcomings and failing to
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252  provide answers to some situations, has remained persistent in addressing the
needs of today’s learner with its basic constructs along with some evolution and
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253 

254  modifications. The paradigm may be called extinct or abandoned in theory, but
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255  for all practical purposes it remains alive and stands strong to provide a healthy,
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256  complete and meaningful learning experience to the learners.

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257 

258  Disclaimer: The text is based on an assignment that was part of a Master in
259  Health Professional Education programme.
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260  Conflict of interest: None.

261  Source of Funding: None.
262 

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378  25. Yarbrough JR. Adapting Adult Learning Theory to Support Innovative,

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379  Advanced, Online Learning -- WVMD Model. Res High Educ J [Internet].

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380  2018 [cited 2019 Oct 13];35. Available from:

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381  https://eric.ed.gov/?id=EJ1194405

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382  26. Schneider SM, Morris EK. A History of the Term Radical Behaviorism:

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383  From Watson to Skinner. Behav Anal [Internet]. 1987 Apr 8 [cited 2019

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384  Feb 26];10(1):27–39. Available from:
385  http://link.springer.com/10.1007/BF03392404
386  27. Ruiz MR. B. F. skinner’s radical behaviorism: Historical Misconstructions

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387  and Grounds for Feminist Reconstructions. Psychol Women Q [Internet].
388  1995 Jun 24 [cited 2020 Jan 10];19(2):161–79. Available from:
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389  http://journals.sagepub.com/doi/10.1111/j.1471-6402.1995.tb00285.x
28. Nalliah S, Idris N. Applying the learning theories to medical education: A
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390 

391  commentary [Internet]. International e-Journal of Science, Medicine &

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392  Education 2014 p. 50–7. Available from:

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393  https://pdfs.semanticscholar.org/a66c/0e5c0ee34546d30403f21616cfa581
394  56c9fb.pdf
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395 

396  ---------------------------------------------------
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397 
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398  Table 1: Key words used for literature search.

Key words used for the literature search
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Behaviourism/ Evolution of Modifications in History of

Behaviorism/ radical Behaviorism Behaviorism Behaviorism
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behaviorism
Behaviorism and Behaviourism and Implications of Theories of
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medical education Education behaviorism in behaviorism

education
399 

400  ---------------------------------------------------
 15 

401 

402  Table 2: Frequency of themes present in the selected articles.

Yes

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Themes N %

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Overview & Critique of Behaviourist theories 19 90.5
Implications in medical education or
16 76.2
education

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403 

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404  ---------------------------------------------------

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405 

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406  Table 3: Frequency of Ideas of Behaviourism used in current medical
407  education

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Feedback 5 23.8

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Learning objectives, clear protocols, pre-
briefing 8 38.1
Instructional design, modular learning, 3 14.3
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Reinforcement theory, Law of Effect,
Premack principle, incentives & rewards 14 66.7
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408 

409  --------------------------------------------------------
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410 
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411 

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412 

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1.Identify research How Behavioral approach has evolved over time to
413  question

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address the needs of today’s learner?

414 
2.Identify relevant Three databases including Google Scholar, PubMed and

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415 

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studies ERIC were searched using identified key words (given in

416  Table 1)

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417 
Revised question was to find out the evidence
Revised research

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418  available in literature for current applications of
question and keywords

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Behaviorist Approach in medical education and
419 
prove that BA is still alive
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420 

421  Inclusion criteria was based on presence of any following

themes:
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422  1. Original theories or laws or basic assumptions of Behaviorism

described in the article as given by Watson, Skinner,
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Thorndike, Pavlov.
423  2. Critique on behaviorism present.
4531 
3. Difference between Radical & Methodological B given RESULTS
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424  4. Uses in education, the roles of teacher & student and

Implication in Medical Education specifically and Education
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generally.
Exclusion criteria was:
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1. Articles with detailed philosophical discussion.

2. Article with application of BA in psychology or behavior
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Management.
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425 
3.Study selection

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426 

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The literature search generated 38 articles in ERIC
database, 14 in PubMed and 15,700 in Google Scholar
using key words “Behaviorism and Education”.

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Whereas, Google scholar generated 2970 articles with
key words “Medical Education” implication of B. The

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key words used for initial general literature search and

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After reading the titles and abstracts 5 articles were

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selected from ERIC, 2 from PubMed and 15 from Google
Scholar. Because of time and resource limitation I
decided to scrutinize only first 3 pages of Google
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Scholar for titles and abstracts.
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A unique no was given to each article before data was

charted in Microsoft Excel. The general info of the
4. Charting the data
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articles key themes and sub themes were identified

according to the research question. This included
information on Topic, Author, Journals, Vol(issue)
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Year, Country of origin, Page no, Abstracts and themes

including : laws of Behaviorism basics &history,
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implications or interpretations of various laws , roles of

students according to BA and implications in current
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medical education.
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427   

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428   

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429   
5. Collating Microsoft Excel was used for collating and summarizing
the data based on general information and specific

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430  summarizing and
reporting results information related to the identified themes. Group
431   
discussion was done with two colleagues to discuss the

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432   
themes and make meaning out of data.

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433   

434 

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435 

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436  Figure 1: Study flowchart.

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437 
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438 

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439 
440  Figure 2: Countries of origin of the selected publication
441  UK: United Kingdom; USA: United States of America.
442 

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443 

444 
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445 
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446  Figure 3: Types of publications selected for review.

447 
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