The examination of the Fellowship of the College of Diagnostic Radiologists South Africa (FC Rad Diag [SA]), conducted by the College of Radiologists (CR) of the Colleges of Medicine of South Africa (CMSA), is the single exit examination required to qualify as a radiology specialist across South Africa. A Master of Medicine (MMed), which is the research component, is also a prerequisite for registering as a specialist with the Health Professions Council of South Africa (HPCSA). The CMSA has been tasked to conduct a national examination that is independent, fair and efficient.¹ The FC Rad Diag (SA) examination is closely modelled on the Fellowship of the Royal College of Radiologists (FRCR) in London with the aim to remain on par with international standards.²

The FC Rad Diag (SA) examination currently consists of two components: Part 1 (radiation physics a 3 h written paper and imaging anatomy, two or three spot tests with no oral component); and Part 2 (3 written papers, a rapid reporting session and long cases). Unlimited attempts are allowed for Part 2, but this must be achieved within 8 years of obtaining Part 1 or the candidate will be required to repeat the Part 1 examination.³ The CMSA entry requirements to the Part 2 examinations include completion of 36 months of training as a radiology registrar in an HPCSA-recognised post, passed or exempt from the Part 1 examination and completion of a performance portfolio or logbook with a satisfactory continuous assessment signed by the head of department.³ The preparedness for any examination by a candidate is multifactorial. This places the spotlight on what factors influence candidate performance and ultimately, success.

Failure rates in training programmes for specialist examinations are high across different specialist medical colleges.^4,5 This has prompted research that has identified a range of potential reasons for failure, including trainee personal factors^6,7 and examination preparation factors.^4,7 Trainee personal factors include age, ethnicity, undergraduate degree training institution, and possession of a postgraduate degree.^6,7,8 Examination preparation factors include the development of a structured study plan, the presence of support structures, and understanding the examination format.⁴

A study carried out in the United Kingdom (UK) looked at the success in the FRCR Part 2B (UK) examination from 2006 to 2010.⁸ Factors such as gender, ethnicity, number of attempts at the examination, presence of an undergraduate and postgraduate degree and place of radiology training were evaluated to assess the impact on the examination outcome of the candidate. Among other findings, the study demonstrated that those who trained within the UK performed better than those who trained outside the UK and that the FRCR 2B examination for UK candidates was unprejudiced with respect to gender and ethnicity.⁸ There is currently no local research on the pass rates and factors influencing the success of candidates training in South Africa.

On 23 March 2020, the president of South Africa declared a national lockdown because of the global coronavirus disease 2019 (COVID-19) pandemic.⁹ This had a great impact on service delivery in healthcare in the country. There was a disruption to personal and professional life as well as to the academic training of radiology registrars. Compliance with the pandemic restrictions, which included social distancing and infection control with the wearing of personal protective equipment (PPE), changed the dynamic of the general workflow.¹⁰ Staff shortages were the result of a reduction in the number of radiology registrars working at a particular time in order to reduce the spread of the virus in the workplace, which was further compounded by registrars who tested positive for the virus and were required to isolate.^10,11 The shortage in the workforce and movement restrictions were particularly challenging for the University of the Witwatersrand (WITS) radiology circuit, where all registrars are required to rotate through various hospitals to gain clinical experience and exposure. Because of the restriction on movement, registrar rotations to these hospitals were completely stopped, and exposure to the different ‘special blocks’ and radiology modalities that included paediatrics, mammography, interventional radiology, CT, MRI, fluoroscopy and ultrasound, was limited. Furthermore, radiology registrars had to be redeployed to work in other clinical disciplines, mainly internal medicine, to assist with the crisis. The academic lectures that historically had always been ‘face to face’ were halted, along with multidisciplinary meetings with other specialities. This led to the introduction of online lectures and multidisciplinary online meetings, including frequent webinars hosted both locally and internationally. Overall, there was a negative impact on radiology training during this time. In line with social distancing practices, the pandemic led to a change in the examination structure, replacing the oral and handwritten components with a fully computer-based, typed examination.

The purpose of this study is to identify the factors affecting pass rates in the FC Rad Diag (SA) Part 2 examination and to explore the frequency of success. While the focus of this study is on the factors influencing examination outcomes, it is important to observe that the study period was interrupted by the COVID-19 pandemic. This disruption may have further impacted examination success rates, which will be considered in the analysis as an additional factor.

This was a descriptive, quantitative study that analysed the factors influencing the outcomes of the FC Rad Diag (SA) Part 2 examination. The study population consisted of all candidates who wrote the FC Rad Diag (SA) Part 2 examination during the period 01 January 2015–31 December 2023.

The database of the CMSA was accessed to retrieve statistics on factors influencing examination success and outcomes within the defined study period. A Microsoft Excel spreadsheet was used to capture the following data: demographic factors (age, marital status, post held at time of the examination); educational background (place of undergraduate training – whether in South Africa versus outside South Africa, the presence of a postgraduate qualification, and exemption to the CMSA Part I examination); examination-related factors (number of examination attempts, year of latest examination attempt, semester of sitting, and year of passing Part I).

The aim of this study was to determine the overall pass rate and factors affecting examination outcome for the FC Rad (SA) Part 2. The observed overall pass rate of 85.7% was higher than that reported for the FRCR Part 2B (UK) at 59.4%.⁸ It is possible that variations in pass rates resulted from different study periods between this study and the UK study, which described data for the 2006–2010 period. Changes to the examination formats in the FC Rad Diag (SA) Part 2 were also implemented in the 2010–2011 period, including introducing a digital platform for long cases and rapid reporting, which might have had an impact on pass rates.¹² Decreased pass rates have been linked to factors such as gender, ethnicity, and non-UK place of radiology training in the UK study.⁸ This study found that younger age, post at time of the examination, pre-2020 examinations, passing at first attempt, and less time elapsed between MBBCH or MBChB and the Part 1 to Part 2 examinations, had a positive association with the examination outcome.

Age was found to play a role in the outcomes of the Part 2 examination, with younger candidates passing the Part 2 examination more frequently than older candidates. This outcome was similar to the findings in a study by Gao et al. in China, which showed that one of the factors that negatively influenced examination outcomes was advanced age. It was postulated that older candidates would have difficulty adjusting to new standardised training requirements after having had clinical work experience and developed personal work habits.⁶ Their study also observed that candidates with a lower number of years after completing medical school were more likely to pass the examinations.⁶ The present study is comparable, also noting that candidates with a shorter time period between medical school and Part 2 examinations were more likely to pass. A shorter gap between foundational medical training and specialisation may be advantageous, potentially because of better retention of core medical knowledge, continued academic momentum and stronger study habits.⁶

Medical officers had lower pass rates and more examination attempts compared to registrars, including supernumerary registrars. Supernumerary registrars are sponsored, unpaid registrars or non-South African registrars without permanent resident status in the Republic of South Africa; the majority originate from African countries with limited or no access to specialist training.¹¹ One explanation for lower medical officer pass rates could be that medical officers attempting the examinations are no longer part of the formal registrar training programme and may lack adequate supervision and access to teaching resources such as examination-focused tutorials and practice examination material. This is possible because most medical officers, after completing their registrar time, are required to vacate their registrar post for the incoming new registrars. This often means leaving the academically accredited training hospitals to seek employment as a medical officer in smaller regional hospitals without a formal, academically inclined radiology training programme. In contrast, registrars and supernumerary registrars work within supervised training programmes where mistakes and gaps in knowledge can be identified and rectified.¹³ Inadequate supervision may contribute to increased stress and reduced motivation, both of which are associated with poorer examination performance.¹⁴ Furthermore, medical officers are less exposed to the daily academic rigours of tutorials, case presentations, internal department assessments and multidisciplinary meetings that are aimed at preparing the candidate to pass the examination. Registrars were therefore more likely to be better prepared for the examination than their medical officer counterparts.

Failure to pass the examinations on the first attempt was a significant risk factor for subsequent failures in the FC Rad (SA) Part 2 examination. This finding was concordant with a similar study in the UK on the FRCR Part 2B examination, where a reduction in pass rates was found with an increasing number of attempts.⁸ Multiple unsuccessful examination attempts add a significant mental burden and stress, as career progression is on hold until success in the examination is achieved, which can adversely affect performance.^14,15

The COVID-19 pandemic had an impact on radiology training with changes in the workflow, academic programme and examination format.^16,17 This study showed a significant increase in failure rates recorded from the year 2020 and onwards, after the COVID-19 national lockdown was declared in the country. The change in examination structure from written and oral examinations to a completely computer- based typed exam was likely a contributing factor. A study performed in 2016 on the Review of FC Rad Diag SA examination results over ten years explored the changing examination format and its effect on the examination results.¹² The study showed a significant reduction in the FC Rad (SA) Part 2 pass rates when the examination format had been changed to include a digital platform, among other changes.¹² Possible explanations include candidates’ unfamiliarity with the digital software and technical issues affecting candidate performance. Simulated assessments in the new format could help candidates become more familiar with the structure and improve examination preparation. A study by Veerasuri et al. confirmed that radiology workload decreased in response to COVID-19, with decreased subspecialty experience and a lack of subspecialty training.¹⁶ The reduction in adequate training is likely another contributing factor to increasing failure rates since 2020.^18,19 Furthermore, the negative psychological impact of the COVID-19 pandemic on candidate performance likely played a role in the examination outcome.^10,20

The analysis of the FC Rad Diag (SA) Part 2 examination data suggests that although pass rates are high, the factors that influence success are multifactorial. Candidates are encouraged to write and pass the Part 2 examinations within the registrar programme, as this study finds that the chances of passing are much higher within formal registrar training posts. Candidates are encouraged to pass on their first attempt, as there is a high risk of subsequent failures after a single attempt. The COVID-19 pandemic, with the change in examination structure, had a significant impact, with a reduction in the pass rates. These insights may inform candidate preparation strategies and guide training institutions in supporting examination success.