By: Fremen Chihchen Chou, MD, PhD
Situated agency, system responsiveness, and the work of making CBME meaningful
A resident finishes a busy emergency department shift. Before leaving, they open the assessment platform and pause. Which case should I submit? Which supervisor will give useful feedback? Is it safe to show that I struggled today? Will a low rating help me learn, or will it follow me into the next competency committee meeting?
These are small questions. They may happen quietly, at the end of a long shift, often without anyone else noticing. But for me, they reveal something important about competency-based medical education (CBME). Learner engagement in CBME is not simply about whether learners are motivated, compliant, or “buying into” the system. It is also about how learners interpret the system in which they live.
CBME promises assessment for learning. It asks us to use workplace-based assessment, feedback, portfolios, and competency committees to support development over time. Yet in daily clinical practice, assessment is never only a tool. It is also a social encounter, a record, a signal, and sometimes a risk.
This question has stayed with me after studying learner engagement in an emergency medicine CBME program in Taiwan. Learners did not simply engage or disengage. They interpreted each assessment encounter: its purpose, credibility, usefulness, and possible consequences. Their participation shifted depending on who observed them, how feedback was given, how documentation might be used, and whether vulnerability felt educationally safe.[1] This helped me think of learner engagement as situated agency.
By this, I do not mean that learners are completely free to choose how they engage, or that engagement is simply a personal trait. Agency is always situated. Learners act within relationships, hierarchies, histories, assessment structures, and imagined futures. They bring past experiences, future concerns, and present judgments into each act of participation. This resonates with Emirbayer and Mische’s view of agency as temporally embedded: shaped by past experience, oriented toward future possibilities, and judged in the contingencies of the present.[2] In CBME, a learner’s decision to submit—or not submit—an assessment is therefore not a simple behavior. It is a judgment made in context.
A learner may choose a trusted supervisor not because they are trying to manipulate the system, but because previous experience has taught them where meaningful feedback is more likely to occur. Another may avoid documenting a difficult encounter not because they reject feedback, but because the system has made vulnerability feel unsafe. A senior resident may seek a “smooth” assessment not because they have stopped learning, but because they understand how documentation may be interpreted later. When seen this way, strategic participation may not mean that learners misunderstand CBME. Sometimes it means they understand the lived system too well.
This is where I think we may need a shift in attention. We often ask whether learners are engaging with assessment, submitting enough forms, or using feedback. These are reasonable questions, but they are not enough. We also need to ask: What are learners learning about the system from the way assessment is actually enacted?
If assessment feels like judgment, learners will protect themselves. If feedback feels generic, they will stop seeking it. If direct observation is rare, documentation becomes symbolic. If low scores carry reputational weight, learners will avoid authentic vulnerability. If forms do not match real clinical exposure, the system may feel inaccurate or unfair. These responses are not merely learner problems. They are implementation signals.
This idea became clearer to me through Aprimadya’s interpretive view of policy implementation. Implementation, he argues, is not only the rational execution of formal objectives; it is also a process of meaning-making. Actions that appear to deviate from official goals may reveal how actors are navigating competing meanings, constraints, and dilemmas in context.[3] I find this very useful for CBME. When learners participate selectively, protect their image, or treat documentation as an administrative task, we may be tempted to label these behaviors as resistance, poor engagement, or lack of feedback literacy. But an interpretive view of implementation asks us to look deeper. What dilemmas are learners facing? What meanings do they attach to assessment? What risks do they perceive? What does their behavior tell us about the system we have built?
In other words, learner engagement is not only an outcome of CBME implementation. It is also feedback about CBME implementation. This brings me to system responsiveness: the capacity of a training program to notice, interpret, and adapt to how CBME is actually experienced. Responsiveness is not just making technical adjustments. It is the ongoing work of keeping CBME educational.
A responsive CBME system asks whether assessment tools still align with clinical practice, whether expectations fit different stages of training, whether direct observation is structurally possible, whether supervisors understand what they are observing, and whether documentation is being rewarded more than meaningful feedback. In a responsive system, assessment is more likely to be experienced as developmental. Learners can show weakness, receive targeted feedback, and use the system for growth. In a less responsive system, assessment becomes more compliance-driven, and learners become more strategic, defensive, or disengaged.
This does not mean that learners have no responsibility. Learners still need feedback literacy, openness, and commitment to growth. But, responsibility should not be placed only on the learner. Engagement is co-produced. It emerges from the interaction between learner agency and system conditions.
Perhaps the sustainability of CBME depends less on asking learners to comply more, and more on building systems capable of responding better. Situated agency helps us see how learners live within CBME; responsiveness asks whether CBME can learn from that experience.
CBME was never meant to be only an assessment architecture. Its deeper promise is developmental: to support learners toward safe, adaptive, and reflective practice. That promise will not be fulfilled by more forms alone. It requires relationships that make feedback credible, structures that make observation possible, cultures that make vulnerability safe, and systems that can adapt when learners show us that something is not working.
So when learners adapt to CBME, perhaps CBME should adapt back — not by abandoning standards, not by lowering expectations, but by listening more carefully to what learner engagement is telling us. Because when learners pause before submitting an assessment, they are not only deciding how to participate. They are also revealing how CBME is being understood. And if we can learn from that pause, CBME may become not only implemented, but meaningful.
Refrences:
- Chu Y-J, Sie Y-D, Chou FC. Mechanisms of learner engagement in competency-based medical education: A grounded theory study in emergency medicine. Medical Teacher. Published online April 15, 2026. doi:10.1080/0142159X.2026.2654625
- Emirbayer M, Mische A. What is agency? American Journal of Sociology. 1998;103(4):962–1023. doi:10.1086/231294
- Aprimadya MH. Rethinking situated agency: an interpretive framework to policy implementation. Policy Studies. Published online August 20, 2025. doi:10.1080/01442872.2025.2547859
About the Author:
Fremen Chihchen Chou, MD, PhD, is an Emergency Physician, Associate Professor at China Medical University, and Director of the Center for Faculty Development at its affiliated hospital in Taiwan. Since 2011, Dr. Chou has successfully led CBME training reforms for the Taiwan Society of Emergency Medicine. .
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