Abstract Background How acceptance of evolution relates to understanding of evolution remains controversial despite decades of research. It even remains unclear whether cultural/attitudinal factors or cognitive factors have a greater impact on student ability to learn evolutionary biology. This study examined the influence of cultural/attitudinal factors (religiosity, acceptance of evolution, and parents’ attitudes towards evolution) and cognitive factors (teleological reasoning and prior understanding of natural selection) on students’ learning of natural selection over a semester-long undergraduate course in evolutionary medicine. Method Pre-post course surveys measured cognitive factors, including teleological reasoning and prior understanding of natural selection, and also cultural/attitudinal factors, including acceptance of evolution, parent attitudes towards evolution, and religiosity. We analyzed how these measures influenced increased understanding of natural selection over the semester. Results After controlling for other related variables, parent attitude towards evolution and religiosity predicted students’ acceptance of evolution, but did not predict students’ learning gains of natural selection over the semester. Conversely, lower levels of teleological reasoning predicted learning gains in understanding natural selection over the course, but did not predict students’ acceptance of evolution. Conclusions Acceptance of evolution did not predict students’ ability to learn natural selection over a semester in an evolutionary medicine course. However, teleological reasoning did impact students’ ability to learn natural selection.