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SAMJ: South African Medical Journal

versão On-line ISSN 2078-5135
versão impressa ISSN 0256-9574

SAMJ, S. Afr. med. j. vol.106 no.12 Pretoria Dez. 2016 



Research competency and specialist registration: Quo vadis?



C P SzaboI; S RamlallII

IMB BCh, MMed, FCPsych, PhD, MSc Med (Bioethics and Health Law); Department of Psychiatry, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
IIMB ChB, FCPsych, PhDDepartment of Psychiatry, School of Clinical Medicine, College of Health Sciences, University of KwaZulu-Natal, Durban, South Africa





The requirement of 'research completion' as necessary for specialist registration with the Health Professions Council of South Africa (HPCSA) has recently been subject to legal action, with a court order potentially shifting requirements beyond those envisaged by the HPCSA. The research requirement is congruent with National Department of Health strategy in this regard, i.e. the strengthening of research as a stated priority. While the expectation of research competency is not in itself contentious, the capacity of institutions and the ability of registrars to facilitate and complete, respectively, have brought the issue into focus. Specifically, the apparent discrepancy between a court order and a regulation needs to be resolved to ensure that specialist registration is not unduly hampered, while ensuring that a potentially important contributor to a national priority is not prejudiced.



The Standards Generating Body (SGB) Subcommittee of the Medical and Dental Professions Board (MDPB) reported in November 2010 on the low compliance with the exit outcomes related to registrar requirements to undertake and complete a relevant research study. In an attempt to align the qualification of specialists and subspecialists with the Higher Education Qualification Framework (HEQF) of South Africa (SA), the new requirements for registration of specialists in SA would include the completion of a research study with a minimum of 60 credits in terms of the National Qualifications Framework.[1] The date of implementation, together with other changes, was 1 January 2011.[1] The inculcation and promotion of a culture of research has clinical and academic merit, as well as implications for providing a local evidence base for the policies of both the National and Provincial Departments of Health.[2] However, implementation of completed research, supervised by the Head of Department, as a mandatory requirement for specialist registration has highlighted the distinct roles and responsibilities of the various stakeholders involved in the registrar-to-specialist process.


Registrar training

Specialist training has evolved. This is both a desirable and necessary development. How educators have understood what works best in terms of teaching and assessment, and how clinicians have understood what constitutes core content for specialist knowledge and core competencies for specialist practice, have contributed to the status quo. The SGB, noting the lack of uniformity of specialist training programmes with respect to syllabuses and assessments - including the assessment of research knowledge and skills - defined new requirements for specialist registration.[1] With respect to the research requirement, it is required that this would be assessed at individual university level as opposed to the single exit examination which fell under the jurisdiction of the Colleges of Medicine of SA (CMSA).

It may be argued that, in the overall pursuit of objectivity and alignment of medical training requirements with other higher education training programmes, processes have become more technical and, at times, overwhelming for both educators and trainees in specialist training platforms. Legally, the impetus has been as much about fair as it has been about defensible. The exponentially increasing content in all fields of medicine demands a rational approach to prioritising what specialist trainees need to know. Within the CMSA, individual Colleges have been required to undertake 'blueprinting' of individual syllabuses with explicitly stated and concisely defined training requirements, core knowledge and requisite competencies which, in turn, would inform examination content and methods. Academic imperatives and the increasing frequency of legal challenges to examination results highlighted the need for assessment methods to be revised to meet pedagogical standards of validity and reliability as well as withstand legal scrutiny. Into this changing scenario and evolution from medical education to medical pedagogy was added the need for specialists to demonstrate competence in research.[1] It would seem that the amended Health Professionals Council of SA (HPCSA) regulation will facilitate the National Department of Health goal of increasing relevant research[2] (recommendations from the National Health Research Summit[2] were incorporated into the Department of Health Strategic Plan 2014/15 - 2018/19).

Research requirements in the College of Psychiatrists

There has been an ongoing process of revision of regulations to align syllabus content with the aforementioned developments. The inclusion of research within the regulations as a requirement for entry to the Part II examination of the Fellow of the College of Psychiatrists (FCPsych) aligned the College with the HPCSA requirement for proof of research competence as a requisite for specialist registration. In this respect Psychiatry was not alone, with other Colleges, e.g. Obstetrics and Gynaecology, within the CMSA having likewise included a research component. However, while competence in research is a requirement for entry to the Part II final and exit examination (administered by the CMSA) and a requirement for registration as a specialist (by the HPCSA), it is ultimately the various universities that manage the acquisition of the research competency. To this end, the successfully examined research report is the third part that follows the successful completion of the Parts I and II examinations leading to the awarding of the MMed degree at university level. The Part II examination conducted by the CMSA is the only specialist exit examination recognised by the HPCSA, while the Part I can be university administered (as a component of the MMed degree) or CMSA administered. In either case, all registrars are required to be registered at their respective universities for the MMed degree when commencing their registrar training. This complex tripartite system upholds the pillars of academia for specialist training while the trainees are all full-time employees of the fourth stakeholder on the registrar training platform, the Department of Health.

The local shortage of medical doctors in a setting of significant financial constraints in the public health sector highlights the need to not only train more doctors but to ensure a smooth and efficient 'pipeline' that will serve the best interests of both academic institutions and health service delivery. The registrar training period has remained fixed at 4 years in general while the medical knowledge base grows continually; academic standards demand concise curricula and comprehensive formative and summative assessments. The implementation of the mandatory completion of the research component as a prerequisite for specialist registration raises questions about the adequacy of the current training period to meet the rigorous training requirements, as well as the respective roles and responsibilities of the four key stakeholders who serve as gatekeepers. The noble intentions underlying the mandate - academic, clinical and research - must be weighed against matters of pragmatism and practicalities.

Legal challenge to the HPCSA requirement initiated by registrars in KwaZulu-Natal[3] warrant closer scrutiny of the status quo and, for illustrative purposes, the College of Psychiatrists will be used as an example (the legal challenge will be discussed in further detail later in the article).


Roles and regulations

CMSA/College of Psychiatrists, universities

The content of the College of Psychiatrists' regulations related to research provides a clear description of what is expected.[4] Specifically, it is stated that there should be research experience as evidenced by, at minimum, a first draft of the research report approved by a Head of Department and supervisor. The requirement was implemented in response to the decision of the HPCSA's Subcommittee for Postgraduate Education and Training - communicated in November 2010 - whereby completed research would become a requirement for specialist registration for all registrars commencing training in 2011, i.e. qualifying in 2015. The initial College content in this regard was open to interpretation insofar as stating that adequate progress should have been made as determined by the Head of Department. This allowed for variation between institutions whereby one institution might be satisfied with protocol completion whereas others might require completed data collection, a research report submitted for examination or a successfully examined research thesis/mini-dissertation.

Such variation in requirements was subsequently not deemed acceptable, given that the College became the national exit examining body with the possibility of a university-obtained MMed no longer being suitable for specialist registration, i.e. only a Fellowship was acceptable. However, given the need for research competence, a university output became a College requirement for entry to examination and an HPCSA requirement for specialist registration. It should be stated that completed research that ultimately contributes towards awarded Master's degrees does translate into much-needed revenue for universities.

The College of Psychiatrists' wording of this requirement was thereafter revised, noting that 'the first draft must comprise data collection and analysis, i.e. a results section, with preliminary content related to the introduction/methods/discussion and conclusion sections'.[4] Such a first draft would technically constitute 'completed' research, albeit not examined towards a higher degree. However, it could be anticipated that such content would be examinable - subject to minor amendments and ensuring that content conforms to the required university academic standards and style requirements. The expectation would thus be that the content conferring eligibility need not have been examined or even submitted as a research report towards the MMed degree but would, at minimum, be work in progress towards examination of and awarding of the Master's degree.

Health Professions Council of South Africa

The HPCSA notes the following in relation to research: 'Completion of a research component will be a requirement for registration as a specialist in South Africa. The research study, which will be assessed at university level, may be used as a credit for Part III of the MMed degree'.[1]

Interpretation of 'may be used as a credit for Part III of the MMed degree' suggests that 'completion of a research component' does not include research that has either been submitted or successfully examined. The content of the Form 57 MED for submission to the HPCSA as part of the specialist registration process states the following: 'We the undersigned certify that the candidate has submitted a research component that complies with the HPCSA requirements and this has been signed off by the research supervisor(s). This research component has not contributed towards obtaining any other degree, including, but not limited to another MMed or MPhil degree'. This can be completed/signed in good faith by the respective Head of Department, Head of School and Dean of an individual Faculty, where a registrar has complied with the College's research requirement for entry to the Part II, as it could indeed be seen as congruent with the HPCSA requirement. However, the issue is how Deans of different institutions, who are required to sign off on the Form 57, will interpret what constitutes 'completed research'. In correspondence with the medical deans (personal communication to Prof. Hift dated 13 October 2015, but with intext reference to a November 2015 meeting of the Subcommittee for Postgraduate Education and Training (Medical)), the HPCSA refers to completion of research being a requirement for specialist registration but does not at any point refer to a completed MMed.

Role players

From the preceding content there are three official role players, each with specific functions and linked to the other as follows:

University - facilitates research process providing supervision/assessment, with higher degree (MMed) throughput the ultimate aim

College - specific research requirement for entry to Fellowship Part II/minimum content stated

HPCSA - research requirement for specialist registration/minimum content stated/facilitated by university and College (through requirement for entry to Part II exam).

Challenges: Clinical, academic and courtroom

The College and HPCSA do not make allowance for universities being unequally resourced to meet the research requirement. A recent study relating to registrar perceptions of the research component noted some specific concerns, such as availability of time, appropriate supervision and necessary skills.[5] While the regulation requiring research completion was in place from 2011, it was challenged legally only in 2015 when HPCSA specialist registration was denied to those who had failed to meet the research requirement.[3] The challenge was upheld, with the judge ruling that the complainants should be registered as specialists, having successfully completed their specialist examinations, but be given a further 2 years to complete the research component. To this end they were to be registered as specialists for the 2-year period but would be removed from the specialist register should they not successfully complete the research component, i.e. obtain the MMed within the 2-year grace period. In reading the court order it is clearly stated that the requirement for specialist registration is a completed MMed as opposed to merely 'undertaking/completing research'. This goes beyond what the HPCSA requirement stipulates. It should be noted that Johannesburg-based doctors had attempted to have the same ruling applied to them but the HPCSA declined to do so.[3]

The legal challenge gives rise to several questions and concerns:

Would the HPCSA be required to amend, through the appropriate committee (Postgraduate Education and Training), its requirements for specialist registration?

Is the court now making a determination on specialist registration requirements, i.e. placing itself above an institution tasked with such a function (given that the institution is served by state/university-employed academics who determine curricula, as well as teach and examine accordingly)?

Would the HPCSA challenge the court ruling in light of potentially being obliged to amend its requirement?

Should registrar training be extended to a 6-year period, accepting that a 4-year period is standard but seemingly inadequate to meet all the training and registration requirements?

The last issue would then place an onus on provincial health authorities to review registrar contracts, with obvious and considerable financial implications. At a National Department of Health level, what would the implications be for numbers of specialists entering practice and how would that relate to planning for service provision? Clearly, the judgement raises many questions - certainly not the least of which is whether the judgement is appropriate or helpful. What the judgement does highlight, without specifically noting such, is that any requirement must be defensible and for successful implementation be unequivocally communicated, as well as, in this instance, be cognisant of the need for all training sites to be able to comply.


Conclusion and recommendations

Investing in the research capacity and calibre of medical professionals and thereby, hopefully, promoting an ongoing culture of research, is a noble endeavour which can only enrich healthcare. The call for greater financial investment in health research within the public sector, to 2% of the national health budget, should be factored into the current issue.[6] Due regard and recognition should be given to the unique role of registrars as registered university students who work in full-time jobs (including overtime) as part of their clinical training, and are required to successfully deliver a Master's-level research project. Achieving this within a defined 4-year training period while honouring the dictates of the employer (clinical training body), the university (academic body), the CMSA (assessment/examining body) and the HPCSA (registering body) is a balancing act. It may be time to open a dialogue that reviews and clarifies the status quo, given adversarial developments that may prejudice the training environment and, ultimately, healthcare.



1. Health Professionals Council of South Africa. Subcommittee for Postgraduate Education and Training. New requirements for the registration of specialists in South Africa. 18 November 2010. (accessed 21 June 2016).         [ Links ]

2. Mayosi BM, Mekwa NJ, Blackburn J, et al National Health Research Summit Report: Strengthening research for health, development and innovation in South Africa. Pretoria: Department of Health, April 2012.        [ Links ]

3. Padayachee K. "Specialist' doctors in fight with council. The Mercury. 3 May 2016.         [ Links ]

4. College of Psychiatrists. Documents attached to the Fellowship of the College of Psychiatrists of South Africa. (accessed 21 June 2016).         [ Links ]

5. Patel N, Naidoo P, Smith M, Loveland J, Govender T, Klopper J. South African surgical registrar perceptions of the research project component of training: Hope for the future? S Afr Med J 2016;106(2):169-171.        [ Links ]

6. Paruk F, Blackburn JM, Friedman IB, Mayosi BM. National expenditure on health research in South Africa: What is the benchmark? S Afr Med J 2014;104(7):468-474.        [ Links ]



C P Szabo

Accepted 20 September 2016



Prof. Szabo and Dr Ramlall are both current members of the Council of the College of Psychiatrists, Colleges of Medicine of South Africa, with Prof. Szabo the immediate past president and Dr Ramlall immediate past and current secretary. Both have been involved in revision to the College's regulations and contributing to the blueprinting process, and are actively involved in postgraduate training at their respective institutions. The article reflects their collective and personal understanding of the issue.

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