Culture, power and practice: Critical discourse analysis of workplace-based assessments in hierarchical postgraduate medical education.

introductionWorkplace-based assessments (WPBAs) are widely promoted as formative tools to promote learning in postgraduate medical education. However, their meaning and effectiveness are deeply influenced by sociocultural and institutional contexts, particularly hierarchy and power relations. Understanding how these dynamics shape WPBA discourses remains underexplored. This study examines how residents' discourse about WPBAs reflects and reproduces hierarchical relations in Pakistan.

methodsThis qualitative study employed Fairclough's three-dimensional Critical Discourse Analysis (CDA) framework to examine WPBA discourses as reflected through residents' language-in-use. Data were collected through semi-structured interviews and focus group discussions with senior medical residents from diverse specialties and institutions across Pakistan. Analysis focussed on textual features (micro level), discursive practices (meso level) and broader sociocultural structures (macro level).

resultsThree themes were identified: (1) WPBAs for Surveillance and Control, where assessments were linked to reputational risk and gatekeeping rather than learning; (2) Hierarchy and Fear of Judgement, highlighted how norms of deference, silence and emotional restraint shaped assessment interactions; and (3) Strategic Compliance to Survive WPBAs, where residents employed adaptive behaviours and self-regulation to minimise risk of reputational damage, loss of clinical opportunities or strained faculty relationships. These findings illustrate how WPBAs are not neutral tools but culturally situated practices that reflect and reinforce institutional power dynamics. DISCUSSION: Our findings indicate that culturally sensitive adaptation of WPBAs requires more than faculty training or checklist refinement; it should consider the communicative norms and power dynamics of everyday clinical education. When assessments are shaped by fear, reputational risk or hierarchical control, WPBAs can undermine their intended developmental purpose. This cautions against uncritical adoption of WPBA frameworks across contexts and emphasises culturally responsive approaches that foster psychological safety, dialogue and genuine learner development. Otherwise, in hierarchical contexts, WPBAs risk functioning as mechanisms of control rather than as tools for feedback and growth.