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.
