Competency-based postgraduate medical education as an institutional initiative in a low- middle-income country: program directors’ perceptions of early implementation

Purpose of the study: Reports concerning implementation of competency-based postgraduate medical education (CB-PGME) are mostly from high income countries where programs are nationally regulated. The present study evaluates implementation of CB-PGME as an institutional initiative in a low- middle-income country (LMIC) where it is not yet a formal accreditation requirement. Study design: An exploratory descriptive qualitative study in mid-2023, eighteen months after initiating transition, used focus group discussions to elicit and analyze program directors’ perceptions of the fidelity of CB-PGME implementation in five selected residency programs of the Aga Khan University (AKU) in Pakistan. Research trustworthiness criteria were duly addressed. Results: Three themes emerged as relevant: understanding of and commitment to workplace-based assessment; integration of learning with clinical work; and alignment of institutional policies for effective governance. Early gains included drawing stakeholders’ attention to CB-PGME; effecting changes in curriculum and assessment; reinforcing the importance of the clinical learning environment; and providing governance at program and institution levels. Simultaneously, deficiencies were observed in faculty’s constructive feedback and timely documentation following workplace-based assessment (WPBA); holistic assessment of residents’ competencies; residents’ understanding of WPBA intent; administration of WPBAs in busy or extended service locations; longitudinal continuity of clinical postings; empowerment of program directors; and alignment of institutional policies. Conclusion: The deficiencies encountered during early implementation of CB-PGME at AKU were like those faced elsewhere and potentially reversible through institutional effort. So, it would be safe to assume that institutional initiatives to implement CB-PGME are feasible in LMIC, while awaiting formal national accreditation.