Transformative learning in behavioral science education: A realist evaluation of medical students’ reflective engagement with cognitive behavioral therapy techniques, case narratives, and humanistic concepts

Medical students often encounter complex psychosocial challenges during their training, particularly when balancing increasing academic demands with emerging professional identities. Behavioral science education aims to equip students with the capacity for reflective engagement, emotional awareness, and patient-centered thinking. This study employed a realist evaluation to examine how a behavioral science course facilitated transformative learning among third-year medical students in Japan. The course integrated cognitive behavioral therapy (CBT) techniques and richly contextualized patient case narratives, supported by humanistic and sociocultural concepts. Data sources included students’ pre- and post-session reflections, group discussions, and final essays collected in 2023 and 2024. Analysis revealed five core mechanisms of learning: structured self-reflection that enhanced emotional literacy; narrative immersion that challenged biomedical reductionism; guided questions that fostered perspective-taking; epistemological disruption through uncertainty; and conceptual framing that legitimized discomfort. CBT-based reflection enabled students to articulate and analyze their own emotional patterns, fostering a readiness to engage in perspective-taking. Case-based discussions challenged biomedical reductionism by presenting realistic dilemmas that exposed students to conflicting values and uncertainties. As students encountered emotionally and ethically complex situations, they demonstrated increased cognitive flexibility, empathy, and tolerance for ambiguity—outcomes consistent with the concept of “troublesome knowledge.” The findings illustrate how the alignment of contextual student needs, carefully designed pedagogical mechanisms, and theoretically grounded content can promote epistemological development and professional identity formation. This study highlights the potential of realist-informed educational design to support critical reflection in medical education, and offers guidance for incorporating similar approaches across diverse cultural and institutional contexts.