Board exams for South African radiology registrars: the playing fields are leveling

The introduction of a single exit exam for all medical specialties is welcome and addresses the perceived incongruence between the examinations offered by the College of Radiologists and the various universities in South Africa. Till now, the dual system in place has caused significant debate and offered examination candidates an alternative route for obtaining a degree acceptable to the Health Professionals Council of South Africa (HPCSA) allowing independent specialist practise.

Supporters of the university-based Master of Medicine (MMed) examinations have in the past consistently maintained that the standards of their examinations have been high, and possibly even of a higher standard than the College examinations. More importantly, however, the MMed examinations with the addition of a research component qualified for a government subsidy and often resulted in the only radiology research conducted in the country. Lastly, the MMed examinations were often conducted in Afrikaans, which gave Afrikaans-speakers an equal opportunity.

On the other hand, the ‘internal’ nature of the MMed examination lent itself to severe criticism, with allegations of leniency towards poor candidates. Even with inviting an external examiner, the locally based examination, the weighted examination panel, internal convener and local examination material would create a particular style of examination that would sometimes not be considered unbiased. Visiting examiners would also tend to be chosen from other universities offering the MMed examinations because of the convenience of reciprocating, and also because of the ability of those examiners to examine in Afrikaans.

Complex scenarios would arise where a candidate failing the College examination would then attempt the local MMed examination. Whether the candidate was better prepared for the second exam or happened to fare better ‘on the day’, would be ignored in favour of the supposition that the MMed examination was of a lower standard – a plainly unfair but unavoidable assumption. In response, some universities offering an MMed exam would set a more difficult exam or sometimes prevent a poor candidate from sitting the College examination for fear of this scenario discrediting their local examination. I personally am aware of 4 candidates who were prevented from sitting the College exam because they were not as well prepared as their local contemporaries, who were allowed to sit the College exam.

The College of Radiologists has been well positioned to take on the role of an independent examining body hosting a national single-exit examination, and has been awarded this responsibility. The College councils and examiner boards, however, are made up of heads of department and examiners who hail predominantly from the universities around the country. The individual colleges must therefore be careful not to replicate the MMed scenario, where examiners at a particular examination centre location originate from that very site or its close affiliates (e.g. Pretoria with MEDUNSA; Stellenbosch and UCT). The College of Radiologists has recognised this (through previous experience) and opted to modify its examination process to include examiners from all universities and some from private practise at every examination, regardless of the location of the examination centre (at the significant cost of flying all of them to the examination centre).

Offering the examination in Afrikaans is more of a problem than a solution. It begs the question ‘Why is the exam not in other languages spoken by the majority of the South African population?’ The examination is best conducted in English, an international language widely spoken in South Africa and the language in which most radiology textbooks currently in use in South Africa are written.

The strategic step of making a research component a prerequisite for registering as a specialist with the HPCSA lays to rest the argument of qualifying for government subsidies. The universities can now provide the infrastructure to produce MMed research which, together with the single-exit examination, qualify for an MMed degree, and therefore a subsidy. This is a greatly welcome mechanism of forcing research back into the training environment and into candidate registrars’ minds.

There are significant challenges for meeting the new requirements. The College has to now demonstrate its ability to host a national exam in an independent and unbiased manner. It must also invest in modern examination techniques including digital platforms, internationally recognised examination methods, and a well trained and expanded examiner panel. Universities also have significant challenges in providing training to ensure success of their candidates in an examination that will be perceived as a measure of the quality of training. Furthermore, those universities without a research history will have to invest time, human resource and possibly money to provide the infrastructure for research. The main challenge for them will be to find adequate supervisors and mentors. Registrar candidates will have to juggle their time to be able to learn ever-increasing radiological information and gain the experience required to practise independently while making time for their research component. The College applications to extend radiology training to a 5-year programme have gone unrewarded by the governing body. To compensate, the College has provided a Part I examination that can be taken prior to entry into the registrar programme. This allows prospective registrars an opportunity to prepare themselves for the registrar programme, gives successful registrar applicants added credentials for being selected into a programme, and provides universities with candidates with proven track records who are ready to start preparing for Part II over a full 4 years.

I am extremely confident that this is the correct way towards producing top-notch radiologists who have been adequately examined in an unbiased fashion. I am also excited at the future, which promises to yield a plethora of radiological publications emanating from local material. I look forward to having radiological leaders who work together under the banner of the College of Radiology of South Africa and alongside the Radiological Society of South Africa, to secure our future.

Professor Savvas Andronikou

Department of Radiology, University of the Witwatersrand

President of the College of Radiologists of South Africa

Chairman of the South African Society of Paediatric Imaging