By: Jamiu O. Busari, MD, MHPE, PhD, CCPE, FRCPC (hons) and Ming-Ka Chan, MD, MHPE, FRCPC
Competency-based health professions education (CBHPE) is widely regarded as one of the most important and enduring reforms in contemporary health professions education. Its central promise is compelling: education organized around demonstrable abilities, meaningful assessment, learner-driven progression, and the needs of patients and communities. In principle, CBHPE should produce better-prepared healthcare professionals, more responsive health systems, and, ultimately, improved healthcare delivery.
Yet one crucial assumption deserves closer scrutiny: that CBHPE is equitable. The global enthusiasm for CBHPE can obscure the fact that educational reforms do not operate in neutral spaces. CBHPE is introduced into systems shaped by unequal access to resources, colonial histories, differing health priorities, professional and other hierarchies, and variable access to technological innovation. If CBHPE is adopted without attention to these conditions, it may reproduce—or even intensify—existing inequities. A central question, therefore, is how equitable competency-based education (CBE) is: for whom, under what circumstances, and according to whose definitions of competence, quality, and success? 1
Language and Equity in CBHPE
At the center of the equity question lies language. CBHPE depends on ongoing communication: educators and assessors describe performance and document observations, learners interpret feedback, competence committees synthesize evidence, and programs decide who progresses. Each component of this process is shaped by language and its potential to influence and be influenced by bias. The way learners are perceived and the decisions made about their performance is influenced by the words chosen, the assumptions behind them, and the contexts in which they are interpreted. This blog explores how culture, context, and communication influence decision-making processes in CBHPE and how language plays a central role in that discourse.
In a 2023 BMJ Leader editorial, the importance of language in promoting anti-racism and social justice in academic writing was highlighted. The editorial noted that terms associated with antiracism and social justice are often used inconsistently. In CBHPE, as in scientific research, this inconsistency matters profoundly. Common examples include equity and equality, which are often used interchangeably, and the usage differs across geographical contexts. Another is sex and gender. Establishing a shared and critically examined language is therefore not merely semantic work; it is a prerequisite for making equity core to everyday work, discussable, assessable, and actionable in healthcare and health education. ²
Language and bias in CBHPE
The issues surrounding language become compounded with collective decision-making processes. CBHPE typically relies on a broad body of assessment information rather than a single examination. Clinical supervisors, peers, other healthcare team members, patients, and care partners may contribute feedback regarding learner performance. Competence committees then consider these multiple data points over time to make high-stakes decisions about progression and readiness for practice. This approach can offer a richer and more authentic picture of a learner. However, more data does not automatically create fairer decisions.3 The value of assessment information depends on whether those who interpret it understand the language, context, and relationships from which it emerged.
Language and gender in CBHPE
Gender offers a clear example of bias in CBHPE. Language within feedback exchanges is often shaped by gender, even when assessors believe they are objective. An assessor’s gender can influence the tone, directness, and type of feedback given, affecting how it is received. A learner’s gender likewise shapes how communication, leadership, and clinical decision‑making are interpreted. Descriptors such as assertive, confident, caring, or hesitant are not neutral; they reflect expectations about who should speak, lead, or show emotion. Women more often receive personality‑based, vague feedback (“opinionated”) rather than actionable, skill‑based comments. The same assertive behavior praised as leadership in men may be labeled “aggressive” in women.4 In reference letters, women are described with communal adjectives (“delightful,” “compassionate”), while men receive agentic ones (“leader,” “exceptional”). Letters for women also include more “doubt raisers” and references to personal life or appearance.5
The consequences are significant, especially when intersecting with culture and context. A man speaking decisively may be seen as confident; a woman using the same style may be judged as difficult. A cautious communicator may appear thoughtful in one setting and indecisive in another. Such perceptions influence feedback, assessments of reasoning, teamwork, leadership, and professionalism. Unless assessors scrutinize their language, gendered descriptions risk becoming embedded as “objective” evidence. Professionalism is another area where language, context, and culture intersect. Language describing professionalism—respectful, reliable, collaborative, patient‑centred—varies across cultures. Behaviors like eye contact, debate, deference, or emotional expression differ in meaning. A learner may seem disengaged when showing respect for hierarchy, or confident when appearing domineering elsewhere. Dress and hairstyle often reflect Western norms. The challenge is distinguishing essential professional standards from culturally narrow expectations.6,7 Programs must clarify what they value and how diverse learners can demonstrate those values, ensuring assessments reward competence, not cultural familiarity
Language and assessment in CBHPE
CBHPE assessment is inherently relational. It is frequently the quality of communication between the assessor and learner that shapes the usefulness and credibility of feedback.8. Learners tend to engage more effectively when feedback is specific, respectful, and psychologically safe.9 These dynamics add complexity for competence committees. Narrative feedback rarely reflects performance alone but also conveys relationships, power, time pressures, and communication norms. Vague comments such as “needs confidence” or “work on communication” invite interpretation without supporting fair educational action. Multisource feedback demonstrates both promise and peril. Its strength lies in integrating diverse perspectives—nurses, patients, and colleagues each observe different facets of performance. Yet interpretation becomes difficult when assessors lack understanding of learners’ cultures, communication styles, or expectations. Disagreement may reflect differing contexts; agreement may signal shared biases. The task is not to collect more feedback but to interpret it critically. Committees must consider whose voices are present or missing, what language is used, and which contextual factors shape each account. They should note patterns in vague, gendered, or culturally loaded descriptors. Faculty development should also address bias in written feedback, while empowering learners to question and contextualize feedback through open dialogue.10
Final Reflections
In conclusion, CBHPE’s promise cannot be fulfilled through frameworks and assessment tools alone. It depends on how people speak, listen, document, interpret, and decide together. By treating language as central to equity, programs can move beyond aspirational statements and toward assessment practices that are more transparent, inclusive, and just. Equitable CBHPE therefore requires a commitment to understanding how communication is impacted by context and culture as a core educational practice, not an administrative afterthought. Faculty development should include attention to language, bias, cultural humility, and the interpretation of narrative assessment. Assessment systems should value specificity over labels and context over assumptions. Finally, competence committees should create space for deliberation and dialogue that asks not only whether the evidence is sufficient but also whether it has been interpreted fairly.
Refrences:
- Busari JO, Chan M-K, Damodaran A, Schwartz A, Ladenheim R, Jones B, Khajehei M,
- Turner DA, Zeleke L, Caretta-Weyer HA, Members of the International Competency-
- Based Health Professions Educators Collaborative. CBE and the Missing ‘E’: Making
- Competency-Based Education an Equitable Framework for Global Health Professions Education.Perspectives on Medical Education. (In Press)
- Busari JO, Chan M (2023) Language matters: in search of a common language for antioppression and social justice in academic writing BMJ Leader 2023;7:e000913.
- Boatright, D., Edje, L., Gruppen, L. D., Hauer, K. E., Humphrey, H. J., & Marcotte, K. (2023). Ensuring fairness in medical education assessment. Academic Medicine, 98(8S), S1-S2.
- Saygin, P. O., & Knight, T. (2026). Gender bias in peer performance evaluations. Journal of Behavioral and Experimental Economics, 102568.
- Khan S, Kirubarajan A, Shamsheri T, Clayton A, Mehta G, (2023). Gender bias in reference letters for residency and academic medicine: a systematic review. Postgrad Med J. 22;99(1170):272-278. doi: 10.1136/postgradmedj-2021-140045. PMID: 37222712.
- Gray, A. (2019). The Bias of ‘Professionalism’ Standards. Stanford Social Innovation Review. https://doi.org/10.48558/TDWC-4756
- Glauser W. (2020) Does medical professionalism have a dark side? CMAJ. 30;192(48):E1646-E1647. doi: 10.1503/cmaj.1095907. PMID: 33257334; PMCID: PMC7721401.
- Young E, Elnicki DM. (2019) Trust as a Scaffold for Competency-Based Medical Education. J Gen Intern Med. 34(5):647-648. doi: 10.1007/s11606-019-04927-6. PMID: 30993625; PMCID: PMC6502872
- Johnson CE, Keating JL, Molloy EK. (2020) Psychological safety in feedback: What does it look like and how can educators work with learners to foster it?. Med Educ. 2020; 54: 559–570. https://doi.org/10.1111/medu.14154
- Performance Evaluations: Decoding Gendered Language in Written Feedback https://residencyadvisor.com/resources/women-in-medicine/performance-evaluations-decoding-gendered-language-in-written-feedback.
About the Authors:
Jamiu O. Busari, MD, MHPE, PhD, CCPE, FRCPC (hons), Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht.
Dr. Busari is a consultant pediatrician and program director of pediatrics at Dr. Horacio Oduber Hospital in Aruba. He is an associate professor of medical education at Maastricht University and the founder of the Jump18 Foundation – Aruba Childhood Obesity Prevention and Intervention Program.
Ming-Ka Chan, MD, MHPE, FRCPC, Max Rady College of Medicine, University of Manitoba, Manitoba.
Dr. Chan is a Professor of Pediatrics and Pediatrics Lead, Antiracism/Social Justice, University of Manitoba, Canada. She is a consultant pediatrician through programs organized under Jordan’s Principle working in Manto Sipi and Nisichawaysihk Cree Nations.
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