Whose Voice Sounds Professional? Accent, Fluency, and the Politics of Communication Assessment in Health Professions Education.

Abstract

Phenomenon: Communication is among the most valued domains in health professions education, yet communication assessment is rarely neutral. Across bedside teaching, workplace-based assessment, objective structured clinical examinations, narrative evaluations, and teaching evaluations, "good communication" can quietly become shorthand for sounding like the locally dominant linguistic group. Accent, dialect, pace, lexical choice, and perceived fluency may then be interpreted as confidence, clarity, professionalism, or fit, even when understanding is adequate and the learner's clinical reasoning and relational skills are strong. These judgments matter because communication ratings are cumulative, subjective, and often high stakes. Approach: This critical perspective uses a linguistic justice and critical sociolinguistic lens to reappraise communication assessment in health professions education. Drawing on recent literature, it distinguishes accent from comprehensibility, multilingual ability from monolingual fluency, and patient-centered communication from assimilation to dominant linguistic norms. It also examines the social meaning attached to speech and how that meaning travels through assessment systems. Findings: Experimental studies that isolate accent within controlled assessment settings have not uniformly demonstrated direct score penalties, suggesting that accent alone is not a simple or universal determinant of poorer marks. However, this does not establish neutrality. Broader literatures show that language functions as a proxy for race and belonging, that faculty accent can influence teaching evaluations, and that narrative and milestone-based assessments can encode patterned bias in impressionistic domains. Meanwhile, evidence from clinical communication, interpreter use, and language-concordant care suggests that what improves care for linguistically diverse patients is not accent conformity but comprehensibility, interpreter teamwork, respectful language, and verified multilingual competence. Current assessment systems often under-measure these capacities while over-valuing linguistic assimilation. Insights: Communication assessment should therefore move away from asking who sounds professional and toward asking what patients can understand, what teams can safely act on, and how learners adapt communication across linguistic difference. This article proposes a justice-oriented approach that makes hidden linguistic norms visible, revises assessment language, audits narrative comments for patterned bias, incorporates interpreter-mediated encounters, and creates rigorous pathways for assessing non-English language proficiency. Reframing communication in this way can make assessment more equitable without weakening standards. On the contrary, it aligns assessment with the realities of contemporary care and with the educational task of preparing clinicians for linguistically diverse health systems.