Pakistan Postgraduate Medical Journal

COMPETENCY-BASED MEDICAL EDUCATION IN PAKISTAN: FROM PAPERWORK TO PATIENT SAFETY

Nudrat Sohail — 2026-04-02

As medical education in Pakistan adopts various programs that can help medical specialists to provide patient care with competency and skills at par with those of advanced countries, the need for Competency-Based Medical Education (CBME) is second to none. CBME aims to produce physicians who can assume responsibility for safe, effective patient care by integrating knowledge, skills, and professional attitudes into observable clinical performance. Its defining feature is the progressive development of learner confidence through repeated, structured, and supervised workplace-based assessments (WBAs), including Mini-Clinical Evaluation Exercise (Mini-CEX) and Direct Observation of Procedural Skills (DOPS). Familiarity with standardized assessment tools, iterative feedback from supervisors, and opportunities for deliberate practice enable learners to refine competencies and transfer them reliably to real bedside settings.

In Pakistan, the Pakistan Medical and Dental Council (PMDC) 2023/2024 undergraduate standards, alongside university curricula, have formally adopted CBME principles such as outcome-based education, portfolios, and continuous assessment. However, implementation gaps persist across clinical environments—from tertiary care hospitals to District Headquarters (DHQ) hospitals—where heavy workloads constrain supervision, feedback remains largely informal, and high-stakes examinations continue to disproportionately shape learner behavior. Without authentic integration into clinical workflows, CBME risks devolving into a checklist-driven exercise with limited impact on patient outcomes.^1–5

As of today, Entrustable Professional Activities (EPAs) represent the operational core of CBME, translating abstract competencies into discrete, observable, and clinically meaningful tasks that trainees can be entrusted to perform independently upon demonstrating sufficient competence. EPAs integrate cognitive, psychomotor, and affective domains, enabling supervisors to make graded entrustment decisions from direct supervision to unsupervised practice. A developmental progression—from foundational EPAs such as history taking, physical examination, intravenous cannulation, and safe prescribing, to more complex activities including informed consent, patient counselling, and procedural performance—facilitates authentic clinical learning. For effective implementation, assessment proformas should be concise (≤5 minutes), feasible across multiple clinical contexts, and used by diverse supervisors to enhance reliability. Systematic documentation of WBAs, structured feedback, and longitudinal portfolio review are essential, with early, milestone-based remediation strategies replacing end-of-year correction. Faculty development remains critical; targeted training in competency assessment and feedback provision, supported by institutional workshops and recognition systems, has been shown to enhance CBME fidelity and sustainability. Strengthening these elements within Pakistan’s resource-constrained yet evolving medical education system can align training with global standards and improve patient care outcomes.^6–10

What is encouraging to know is that medical educational professions in Pakistan have realized that Competency-Based Medical Education (CBME) is an outcomes-based approach that organizes training around the achievement of predefined competencies—integrating knowledge, skills, and professional attitudes—required for effective patient care, with progression based on demonstrated performance rather than time.¹

Historically speaking CBME gained prominence in the early 2000s, particularly through the CanMEDS framework in Canada and the Accreditation Council for Graduate Medical Education (ACGME) competencies in the United States.^11,12 While CBME has been successful in improving transparency of learning outcomes, standardizing assessment, and promoting workplace-based evaluation, early implementation faced significant challenges, including fragmented assessment systems, excessive reliance on checklists, faculty burden, limited feedback quality, and difficulty in translating competencies into authentic clinical practice. ^6,8,13 These challenges are also being observed in Pakistan and senior medical educational professionals can take the lead with the help of technology to help CBME overcome these challenges and move ahead.

Artificial Intelligence (AI) Technology has the potential to both strengthen and challenge CBME. On the positive side, AI can enhance assessment validity through learning analytics, automate workplace-based assessment tracking, support adaptive learning, and provide real-time feedback, thereby addressing longstanding issues of scalability and consistency.^14,15 Conversely, risks include over-reliance on algorithmic decision-making, threats to data privacy, reduced human judgment in entrustment decisions, and potential bias embedded within AI systems, which may undermine fairness and professional development.¹⁶ Thus, while AI offers transformative opportunities to advance CBME, its integration must be guided by robust ethical frameworks and faculty oversight. The need of the hour is to be careful, yet pragmatic and progressive to make judicious use of technology, various CMBE standards and frameworks while empowering the medical education professionals to continuously improve and enhance the CBME process.

A comparative study on the efficacy of Positive Psychology Intervention and Cognitive Behavioral Therapy for Clinical Depression

Dr. Ayaz Muhammad Khan — 2026-04-02

Background: Depression affects millions globally, with a high prevalence in Pakistan. Effective interventions are critical, yet comparative evidence for Positive Psychology Intervention (PPI) and Cognitive Behavioural Therapy (CBT) in reducing depressive symptoms and enhancing psychological well-being among clinically depressed adults is limited.

Objective: To compare the efficacy of PPI and CBT in reducing depressive symptoms and enhancing psychological well-being among clinically depressed patients.

Methods: In a two-group pre-post experimental design, 120 adults with clinical depression were randomly assigned to 12-week PPI (n=60) or CBT (n=60) interventions at Sharif Medical City Hospital Lahore from January to June 2024. Depression was assessed using the Beck Depression Inventory-II (BDI-II) [2], and psychological well-being with Ryff’s Psychological Well-Being Scale (PWB) [3] pre- and post-intervention. Paired and independent t-tests analyzed outcomes.

Results: Both interventions significantly reduced BDI-II scores (p<0.001), with CBT showing a greater reduction (mean difference=9.3) than PPI (6.9, p<0.01). Both increased PWB scores (p<0.001), with PPI yielding a larger increase (81.6) than CBT (69.4, p<0.01).

Conclusion: CBT is more effective in alleviating depressive symptoms, while PPI excels in well-being enhancement, suggesting tailored or integrated approaches for depression treatment in resource-limited settings like Pakistan.

Association of Serum Uric acid with Metabolic Dysfunction associated Steatotic Liver Disease in patients presenting to Tertiary care Hospital/ Uric acid and MASLD

samia kausar — 2026-04-02

Objective: Metabolic dysfunction associated liver disease is on rise, due to changing dietary and socioeconomic patterns and has become global health issue. Elevated uric acid impacts frequency and severity of fatty liver Our objective is to explore the association of serum uric acid with metabolic dysfunction associated liver disease.

Method: This cross-sectional study was conducted at Pakistan Railway Hospital in Medical and Radiology department from 1^st Jan to 30^thJune, 2025. We enrolled 200 patients with MASLD, diagnosed on ultrasound with fatty liver graded to mild, moderate and severe categories. Demographic details, physical examination findings, comorbidities and relevant laboratory findings were entered on structured proforma. Statistical analysis was done by SPSS version 24.

Results: In this study majority were female (63%) and mean age of patients was 48+19 years. About 47.5% had mild fatty liver, 34% and 28.5% had moderate and severe fatty liver respectively. Elevated uric acid levels were seen in 75% patients with highest levels were observed in patients with severe fatty liver (7.62 vs. 5.89 vs. 4.75 P<0.001). Serum uric acid showed strong correlation with fatty liver index FLI (r=0.493, P<0.001) and moderate correlation with FIB-4 score (r=0.261, P <0.001). Life style factors like processed diet, lack of exercise, poor periodontal health are significant contributor to hyperuricemia.

Conclusion: Hyperuricemia has significant prevalence among patients with MASLD and demonstrated association with steatosis and fibrosis in liver.

Rice based ORS versus glucose-ORS in non-cholera diarrhea in children

Muhammad Usman Ajmal — 2026-04-02

Abstract

Objective: To compare the mean reduction in frequency of stool with use of rice-based ORS versus glucose-ORS in children with non-cholera acute watery diarrhea.

Material and Methods: This randomized clinical trial was conducted in department of Pediatrics, King Edward Medical University/ Mayo Hospital Lahore from January to July 2020. Total of 80 patients (40 in each group) were enrolled by simple random sampling and were randomized into group-A (Rice-based ORS) and group-B (Glucose-ORS). Age and change in number of stools were compared using Mann-Whitney U test in both groups (Glucose ORS and Rice based ORS) as data was not normal (Shapiro-Wilk test was used). Chi-square test was applied to compare gender and duration of diarrhea in both the groups. P-value ≤ 0.05 was taken as significant.

Results: The mean age of patients was 5.94 ± 3.80 years and 4.66 ± 3.11 years in rice-based ORS group and glucose-based ORS respectively. Mean change in number of stool in group-A was 1.92 ±0.83 and in group-B it was 2.87 ± 0.82. The mean change in number of stool was statistically higher in group-B when compared to group-A (p-value < 0.001).

Conclusion: Glucose based ORS is better than rice-based ORS in reducing the number of stools in children with non-cholera acute watery diarrhea.

Key Words Oral rehydration salt, Rice based ORS, Glucose ORS, Non-cholera, Acute watery diarrhea.

The relationship between gingivitis and depression in adult female

Dr Rohana Rehman — 2026-04-02

Background:
Gingivitis is a common and reversible inflammatory condition affecting gingival tissues, primarily initiated by plaque accumulation due to poor oral hygiene. Increasing evidence highlights its potential associations with systemic and psychological health conditions, including depression. This study explores the relationship between depression and gingivitis among adult females in Pakistan.

Objective:
To assess the association between gingivitis and depression, while also evaluating oral hygiene behaviors and dietary habits among adult female patients.

Methodology:
A cross-sectional, questionnaire-based study was conducted at the Department of Periodontics, Multan Medical and Dental College, over a period of four months. A total of 267 adult females aged 20–45 years were included using non-probability purposive sampling. Data on oral hygiene practices, depression scores, and gingivitis severity (using the Gingival Index) were collected. Statistical analysis was performed using SPSS version 22, with chi-square tests applied to assess associations between variables.

Results:
The mean age of participants was 33.52 ± 6.78 years. Most were housewives (70.8%) and had low to medium education levels. Brushing once daily was the most reported habit (66.7%), while 80.5% of participants did not use dental floss. There was no significant association between brushing or flossing frequency and gingivitis severity (p = 0.654 and p > 0.05, respectively). Dietary analysis showed a highly significant association between snack intake and gingivitis, though soft drink intake showed no such link. Notably, 65.9% of participants exhibited some level of depression, and the Chi-square test revealed a statistically significant association between depression scores and gingivitis severity (p = 0.020), suggesting that as depressive symptoms increased, so did gingival inflammation.

Conclusion:
This study confirms a significant association between depression and gingivitis among adult females, emphasizing the bidirectional connection between psychological well-being and oral health. Despite adequate awareness of brushing frequency, clinical signs of gingivitis persisted, indicating that frequency alone is not a reliable predictor of oral health. These findings support the need for integrated dental and mental health care strategies, particularly for women in Pakistan, to address the multifactorial nature of oral disease.

Key words: Gingivitis; Depression; Oral Hygiene; gingival Index.

EFFECTS OF PHOTOTHERAPY ON SERUM CALCIUM LEVEL IN NEONATES WITH HYPERBILIRUBINEMIA

Hina Batool Siddiqui — 2026-04-02

Objectives: To determine the effect of phototherapy on serum calcium level in neonates with hyperbilirubinemia.

Methods:Data Collection: It is a descriptive study conducted at Department of pediatrics, PAF Mushaf hospital from 14 March 2025 to 14 September 2025.

Ninety-six neonates who met the selection criteria were enrolled upon providing informed consent; their demographic details were then recorded. Baseline serum calcium levels were measured prior to initiating phototherapy, which was administered for 48 hours. During treatment, all neonates received oral feeding supplemented with 20% intravenous fluids to compensate for phototherapy-related losses. A post-phototherapy assessment of serum calcium levels was conducted at the 48-hour mark, and all resultant data were captured using a pre-designed proforma.

Results: Of the 96 neonates, 61.5% (n=59) were male and 38.5% (n=37) were female. Mean serum calcium declined significantly from a pre-treatment level of 9.25 ± 0.29 mg/dl to 7.32 ± 0.22 mg/dl after 48 hours (mean decrease: 1.93 ± 0.36 mg/dl, p<0.001).

Conclusion: The study found phototherapy to be significantly associated with reduced serum calcium levels in hyperbilirubinemic neonates, noting a significant decline from baseline specifically after the 48-hour.

Frequency of dyslipidemia in type 2 diabetics with overt nephropathy

Hina Pervez — 2026-04-02

Abstract

Objective: To evaluate frequency of dyslipidemia in type 2 diabetics with overt nephropathy.

Methods: This descriptive cross sectional study was conducted on 146 patients of diabetes mellitus in department of Medicine of Pakistan Railway hospital, Rawalpindi from 1^st May 2024 to 31^st October 2024. The sample included the patients of diabetes with overt nephropathy between 30 to 60 years of age. Fasting venous blood sample was collected for serum lipid levels and blood glucose analysis. Dyslipidemia was considered positive if total cholesterol was found > 200mg/dl, serum triglyceride >150mg/dl, LDL cholesterol >130mg/dl, HDL cholesterol < 35mg/dl. Data was analyzed by using SPSS version 24.0

Results: Our study has shown that dyslipidemia was present overall in 50.68% patients while raised LDL-C alone being most prevalent lipid abnormality present in 58.9% patients. Dyslipidemia is significantly associated with increased BMI and female gender.

Conclusion: Our study indicates that dyslipidemia was highly prevalent among diabetic patients with nephropathy.

Key words: diabetic nephropathy, dyslipidemia, type 2 diabetes, chronic kidney disease.

Prospective Evaluation of Arteriovenous Fistula Maturity and Success: Serial Follow-up Using Preoperative and Postoperative Duplex Ultrasound (1st Week, 3rd Week, and 6 Weeks)

Muhammad Idrees — 2026-04-02

Abstract

Background: Arteriovenous fistula (AVF) is the preferred vascular access for hemodialysis. Early maturation and patency are critical for successful dialysis, but outcomes are influenced by patient factors, vessel characteristics, and comorbidities.

Objective: To prospectively evaluate AVF maturation and success using duplex ultrasound in patients undergoing RC-AVF, BC-AVF, and BB-AVF, with serial assessments at 1, 3, and 6 weeks postoperatively.

Methods: Sixty-nine patients undergoing AVF creation at CMH Lahore from January to July 2025 were included. Demographics, comorbidities (diabetes mellitus, hypertension, ischemic heart disease), and fistula type were recorded. Preoperative and postoperative vessel diameters and AVF flow rates were measured using duplex ultrasound. Statistical analysis was performed.

Results: Among the 69 patients, BC-AVFs consistently exhibited the highest mean flow rates and diameters across the postoperative period. Thrombosis occurred in 7–9% of AVFs, predominantly among patients with smaller preoperative vessel diameters and those with diabetes mellitus, consistent with significant negative correlations between vessel size and postoperative flow (p < 0.05). Serial duplex assessments at 1st, 3rd, and 6th weeks enabled early identification of suboptimal flow, allowing timely intervention to optimize AVF maturation.

Conclusion: AVF maturation is influenced by fistula type, preoperative vessel diameter, and patient comorbidities. BC-AVFs demonstrate higher early flow rates, whereas RC-AVFs with smaller vessels are more prone to thrombosis. Older age, diabetes, and ischemic heart disease further increase the risk of early AVF failure.

A COMPARATIVE STUDY OF TWO LEVELS DISCECTOMY WITH OR WITHOUT POSTERIOR INTERBODY FUSION IN A TERTIARY CARE HOSPITAL

Muhammad Zafar Iqbal Shahid Sobia Zafar — 2026-04-02

BACKGROUND:

Lumbar disc herniation is considered as major cause of chronic backache & radiculopathy. Recurrent disc herniation and instability are common with multilevel discectomy while degenerative problems of adjacent segment are more common with interbody fusion.

OBJECTIVES:

To compare the functional outcomes & complications of two levels disc excision with or without posterior lumbar interbody fusion.

METHODOLOGY:

This prospective randomized controlled study was carried out at Department of Orthopaedic Surgery Jinnah Hospital, Lahore from June 2024 to November, 2025. A total number of 50 patients with two levels intervertebral disc prolapse , divided into two equal groups A & B with 25 patients in each group. In group A, we performed discectomy in group A while in group B, discectomy with posterior Lumbar interbody fusion was done. The functional outcomes were evaluated by using Owestry Disability Index(ODI)& Visual Analogue Score(VAS) at 06 weeks, 03 months, 06 months & one year after the surgery.

RESULTS:

A significant pain reduction at 6^th, 12 weeks and 6^th months in both groups but Group A typically shows faster pain relief in the immediate postoperative phase ( p< 0.05), while Group B shows better long-term stability for back pain. VAS Score was 7.4- 7.6 as base line in both groups. At the end of one year, it was 2.0 to 3.0 in group A while 2.8 to 3.5 in group B. There was no significant difference in terms of Owestry Disability Index (ODI) at 6 and 12^th week (p> 0.05) but had a significant difference at 6^th months (p< 0.05).

CONCLUSION:

For L4-5 and L5-S1 herniation, discectomy (Group A) alone offers less operative duration and better pain relief after followup of one year but the recurrence rate of disc herniation is high I.e;22%in our study. Posterior lumbar inter body fusion in group B is more technically demanding and provides a definitive solution for recurrence, making it an alternative option for patients with risk of instability

KEY WORDS: Lumbar Spine, Disc Herniation, Posterior lumbar interbody fusion, Discectomy

Frequency Of Various Dermoscopic Patterns of Pityriasis Versicolor; A Cross-Sectional Observational Study

Javeria Bushra Touqir — 2026-04-02

Background & Objectives: Superficial fungal infections like Pityriasis versicolor (PV) are among the most prevalent dermatological conditions worldwide. Clinical diagnosis is usually straightforward, although certain cases can be confounding, particularly if the presentation is similar to that of other skin disorders. Fungal cultures and potassium hydroxide mounts are traditional confirmatory tools, though each has limitations. The purpose of this study was to investigate the frequency of various dermoscopic patterns in PV lesions, especially those that are hypopigmented, hyperpigmented or mixed plaques presenting to a tertiary care setting in our population.

Methods: In this cross-sectional observational study, a non-probability consecutive sampling strategy was used to analyze dermoscopic patterns of PV lesions with positive KOH mounts from different body regions.

Results: The study comprised a total of 75 lesions from 75 patients. The most common dermoscopic patterns in hyperpigmented lesions (n=46) were scaling (39%), perilesional hyperpigmentation (34%), non-uniform pigmentation (29%), subtle ridges and furrows (26%), and hair follicular invasion (24%). Conversely, the majority of hypo pigmented lesions (n=27) had clearly demarcated borders (29%) and vascular patterns (18%). The dermoscopic patterns found in mixed lesions (n=2) were scaling, perilesional hyperpigmentation, clearly demarcated borders, and non-uniform pigmentation (2%).

Conclusion: Dermoscopy is a cost-effective tool for the diagnosis of lesions of PV that are difficult to diagnose.

Keywords: Pityriasis versicolor, cross-sectional studies, dermoscopy, diagnostic techniques and procedures

Complications and Pitfalls of Tube Thoracostomy: A Comprehensive Analysis from a Tertiary Thoracic Surgery Centre

Zeeshan Sarwar — 2026-04-02

Abstract:

Background and Objectives:

Catastrophic chest injuries are increasingly encountered in emergency settings, requiring prompt and effective management. Tube thoracostomy remains a vital, life-saving procedure for traumatic conditions However, despite its common use, this intervention carries significant risks and complications. This study was conducted to evaluate the frequency, nature, and causes of complications and hazards associated with tube thoracostomy.

Methods:

The (Department name) of the (hospital name) conducted this retrospective analysis from May 2024 to April 2025. The trial involved a total of 800 patients. Common errors related to the care of the tube thoracostomy and its system, as well as complications associated with the tube insertion, were recorded and examined.

Results:

In our study of 700 patients, the majority were aged 12–50 years (68.6%), with 75.1% being male. A total of 244 (34.85%) complications were recorded, predominantly lung parenchymal placement (66.8%), followed by extra-pleural misplacements (20.08%), subcutaneous emphysema (6.96%), abdominal injuries (2.4%), and others. Additionally, 323 (46.14%) procedural hazards were noted, including ineffective placement requiring re-intervention (34.98%), post-procedural empyema or clotted hemothorax needing decortication (25.07%), inappropriate clamping (10.83%), suction mismanagement (8.6%), covered outlet vents (6.81%), few and others.

Conclusion:

Tube thoracostomy is a vital yet potentially hazardous procedure. Our findings highlight that complications are common, particularly in emergency settings and when performed by less experienced personnel. Proper technique, anatomical awareness, and staff education are crucial to minimizing risks. This study reinforces the need for standardized training and adherence to safety protocols in chest tube management.

Evaluation of Pain Outcomes with Articaine Versus Lignocaine in the Endodontic and Surgical Management of Irreversible Pulpitis in Maxillary First Molars

amber rashid — 2026-04-02

Abstract

Objective

Assessment of Pain Levels in Root Canal and Extraction Procedures Using Articaine and Lignocaine Buccal Infiltration in Maxillary First Molars with Irreversible Pulpitis

Methodology

Randomized double blind clinical study

Place and Duration of study

Pharmacology department, Islamic International Medical College Rawalpindi in collaboration with Margalla Institute of Health Sciences.

Study duration was one year.

240 patients being managed for irreversible pulpitis for maxillary first molars were randomly divided into two Groups, Group 1 and 2. Group 1 were the patients given the specific local anesthesia for pulp extirpation (root canal treatment). Group 2 were the patients given the local anesthetic for exodontia (dental extractions). These groups were further subdivided into four groups. Group A and Group B were managed by pulp extirpation (root canal) and were given Lignocaine and Articaine respectively. Group C and Group D were managed by exodontia (dental extraction) and were anesthetized using Lignocaine and Articaine respectively. The pain experienced by the patients during injection and the pain experienced during the procedure was determined by the VAS.

Results

Significantly less pain was experienced by the Group B and Group D patients as compared to Group A and C during the procedure.

There was no statically significant difference in the pain experienced by the patients during the injection

Conclusion

Articaine causes marked decrease in the pain experienced during the procedure and it can be used in the management of irreversible pulpitis.