The CMSA is an independent, not-for-profit, membership organisation, with a paid-up membership of >11,000 medical and dental specialists and diplomates. It was established in 1955, prior to which aspirant specialists had to travel to the United Kingdom to take examinations. Its founding objectives include “promoting skill, efficiency, ethical standards and professional conduct for the benefit of humanity and promoting the honour of the medical and dental profession”.

The CMSA is mandated by the HPCSA to conduct national unitary examinations in all medical and dental specialties and subspecialties on behalf of and in close collaboration with all South Africa’s medical schools. It offers biannual certification examinations in 95 disciplines and confers about 1100 Diplomas, 1100 Fellowships in 38 specialties, and 200 Certificates for subspecialists per annum.

The CMSA is guided by the following core values:

• Transparent in its processes, communication, and leadership structures.
• Responsive and focused on the societal impact of the services it provides.
• Candidates undergoing exams with the CMSA are provided with the right to Equality, Dignity, and Privacy.
• The CMSA strongly endorses internationally recognized standards of human rights, condemns all forms of violence, and is committed to the development of a just and peaceful society in which educational, health, recreational and other social services are available to all.
• The CMSA is opposed to all forms of discrimination on the grounds of race, religion or gender and believes that such discrimination is incompatible with the ethical practice of medicine.

The CMSA has 29 constituent colleges that represent all medical and dental specialties. Its elected leadership is drawn from medical and dental specialists from all training universities and from the private sector. The CMSA is governed by its Senate on academic and examination matters and by its Board of Directors, all of
whom are nominated by and voted for by the CMSA’s members and by College Councils, in a federal structure with a strong centre. The Social and Ethics Committee provides guidance and oversight.

The recent leadership actively transformed the CMSA with a focus on race and gender for which it received a Standard Bank Top Gender Empowered Company award in 2022. The 2020 and 2023 elections show how transformation is consolidated in the CMSA: 70% of the current Board of Directors and 63% of Senators are of colour and 35% of colleges are led by female Presidents. Transformation milestones include electing Prof Flavia Senkubuge as the CMSA’s 1st black female president in 2019; and the appointment of Mrs Yolokazi Kanzi as our first black female academic registrar in 2020.

Current elected and executive leadership of CMSA

The CMSA recently evolved from being principally an examining body, to seeking to fulfil its founding objectives that include “promoting skill, efficiency, ethical standards and professional conduct for the benefit of humanity and promoting the honour of the medical and dental profession”. This includes transformation of the CMSA, building alliances with sister colleges, creating an education platform, establishing a scientific journal, and engaging in advocacy.

The CMSA is forging alliances with sister colleges in other lower- and middle-income countries (LMICs) as we have shared challenges around training and healthcare but also finding solutions to such challenges. The Alliance of Surgical Colleges of Africa comprises the West African College of Surgeons, the College of Surgeons of East, Central and Southern Africa, and the CMSA. It jointly represents 37 countries and hence speaks with a powerful, unified voice to advance surgical education, training, and services in Africa.

Recognising that not all our candidates have access to the opportunities at historically advantaged institutions, the CMSA is building an education platform to assist all candidates preparing for examinations. This will include a library of prepared materials and lectures but also allow for online live tutorials.

The Journal of the Colleges of Medicine of South Africa (JCMSA) was established in July 2023 to provide an open access publishing platform for all medical and dental specialities and basic medical sciences to share research, to assist  registrars to publish MMed dissertations, and to ensure that research from South Africa, Africa and LMICs is included in the global academic discourse. An Article Processing Charges Waiver Fund has been established to ensure that the ability to pay should never be a barrier to sharing research….a matter of equity and social justice.

Given the exceptional depth and width of expertise among its members, the CMSA has established a Health Policy Committee to engage in advocacy, and to engage national and provincial governments and other stakeholders so that the CMSA can share perspectives of specialized medicine in deliberations about the shape and future of our healthcare.

South Africa and Africa have a shortage of medical specialists. To advance care, especially for the rural and disadvantaged, the CMSA confers 20 postgraduate diplomas to about 1100 successful candidates annually. The CMSA is planning to make its diploma examinations available to other countries in Sub-Saharan Africa.

The CMSA is mandated by the HPCSA to conduct unitary national examinations on behalf of the universities. The CMSA is in effect in a 3-way partnership with the HPCSA through the Medical and Dental Board (MDB) of the HPCSA and the Medical and Dental Faculties and Schools, represented by South African Committee of Medical Deans (SACOMD), each with its unique and mutually supportive role – the MDB as the regulator, the universities responsible for education, training, and research, and the CMSA to conduct national unitary examinations. The Council for Higher Education accredits the university MMeds for specialists and MPhils for subspecialists which includes approval of the CMSA as the examiner for their qualifications.

The relationship between the HPCSA and the CMSA is governed by a Memorandum of Understanding in which the HPCSA grants the CMSA authority to run national unitary specialist examinations. The CMSA in turn accounts to the MDB of the HPCSA including reporting on its examinations. More direct insight is offered through the Chair of the MDB attending the CMSA Senate meetings. The CMSA has ex officio representation both on the MDB and its Medical Education, Training and Registration Committee (METRC). The CMSA provides regular reports to the HPCSA.

The leadership of the CMSA works closely with SACOMD. The CMSA and SACOMD meet regularly to discuss training and assessment of specialist candidates and the CMSA provides SACOMD with quarterly updates. The CMSA meets annually with Deans, Faculty, and Registrars alongside each of its 5 regional admission ceremonies in Bloemfontein, Cape Town, Durban, Gauteng, and Mthatha, and the Chair of SACOMD attends and participates in the CMSA’s biannual Senate meetings.

The CMSA’s role has evolved in relation to specialist examinations and certification. Prior to 2012, medical and dental practitioners could register with the HPCSA as specialists either with a CMSA fellowship qualification, or an MMed qualification from their training university. Since 2012, and in accordance with global best practice, the HPCSA requires candidates to write national unitary exit examinations run by the CMSA, with training institutions signing off completion of required training, being clinically competent, and passing MMed research dissertations. Training universities use the Fellowship examination as a theoretical component (all or partly) for their MMed degrees. The CMSA’s role has therefore evolved from being an independent certification body to running a national unitary examination platform in association with all the universities. Examiners, conveners, and moderators are drawn from academic staff of all university training departments, and private practitioners that serve as examiners are all involved in specialist training.

Candidates are qualified specialists who undergo additional higher training at their respective universities and write the CMSA national unitary examinations listed below. Universities have been encouraged to register subspecialist programmes as MPhil courses.

Diplomas are awarded to medical practitioners. Following supervised clinical experience in an accredited hospital in a professional discipline, candidates write the CMSA Diploma examination. The CMSA confers about 1100 diplomas in 20 fields per year. The training equips medical officers to provide specialised care in the fields detailed below. Diplomates deliver a key service of higher quality to the South African public, filling service gaps created by the shortage of specialists, especially in rural areas.

The format and delivery of the CMSA’s examinations have changed significantly in recent years as summarised in the table below and align with evolving international best practice. The new formats address weaknesses of traditional historical formats used both in under- and postgraduate medical and dental programmes internationally and offer not only fairer examinations but also greater certainty of competence of those qualifying.

Standard setting is being introduced and is already operational in several examinations. It represents international best practice, and it standardizes for the levels of difficulty of examinations across examination cycles. It therefore improves the fairness of examinations and hence benefits candidates who may otherwise have been disadvantaged by a more difficult examination.

Several interventions have enhanced the quality and fairness of examinations. These include improved formats of assessment as outlined above and improving quality of examining. The CMSA has invested significant effort into enhancing skills of examiners, e.g. in examination format and in question setting such as in the wording of SBA questions. This has been achieved through webinars, examiner group tutelage and written documentation in examiner packs. The CMSA has also focused on addressing unconscious bias and examiner conduct. Apart from the university academics that serve in the CMSA, the organisation is fortunate to have outstanding expertise in postgraduate medical education and assessment on its permanent staff, who are also actively engaged in improving examination formats and training of examiners, conveners, and moderators. The CMSA is also represented as advisors on the National Workplace Based Assessment Task Team.

The CMSA’s role has shifted from historically administering handwritten examinations over 6 weeks a year to now running online written examinations over 10 weeks a year, and administering clinical examinations that previously were conducted in wards of teaching hospitals, to structured oral examinations by videoconference over 22 weeks of the year. For the oral examinations, candidates attend one of the 8 CMSA examination venues in South Africa or at venues in Southern Africa. Examiners are located anywhere in the country, as long as they have secure internet connection. Designing timetables for each day of oral examinations is very complex, as there are commonly 10 - 20 examiners and 30 - 60 candidates, with each having to know exactly which of >100 separately booked Zoom calls to log onto at any given time. Thanks to measures taken to protect exams against power outages and internet failures, the CMSA has not “lost” an exam since it introduced the new system in 2020. Improved efficiencies, upskilling of staff, and administrative reengineering have allowed the CMSA to manage the complexity of the new examination formats with <20% increase in its staffing.

The CMSA has reengineered and oiled its systems to provide an efficient, accessible, and empathetic service to candidates, before, during and after examinations. The CMSA provides “candidate’s packs” and runs national webinars to explain all the processes and systems to candidates every semester that are recorded for candidates who can’t attend. Every examination has an administrator allocated to it to whom candidates can direct queries. The Academic Registrar has “open hours” every week; any candidate who wishes to address a query at executive level simply has to self-book an appointment. There is a big focus on turnaround time for results and the CMSA is achieving its aim of releasing results within 6 weeks.

Geographical transformation is another transformation pillar of the CMSA. Prior to the Covid pandemic, candidates had to travel to a single national examination centre (Bloemfontein / Cape Town / Durban / Johannesburg) for their clinical examinations and admission ceremonies. To support regional equity, the CMSA now has 8 regional examination centres, equipped with laptops, secure internet connection, backup power, IT support and invigilators to limit time, travel, costs, and stress for candidates and examiners. There are also 3 examination centres in the Eastern Cape Province where there had been none previously. Candidates have indicated that the new regional examinations not only save them money, but being at home and in familiar setting offers a much more supportive environment and improves their examination performance. Admission ceremonies are now held annually in Bloemfontein, Cape Town, Durban, Johannesburg and Mthatha to allow candidates, friends, and family to celebrate candidates’ success. The costs of the examination centres and admission ceremonies are borne by the membership of the CMSA.



South African and International CMSA examination centers

The CMSA was been running national unitary examinations since the 1950s. In 2012, the South African universities and the HPCSA decided to discontinue the local university MMed examination option in favour of having only the national unitary examinations conducted by the CMSA, with universities using the infrastructure and the expertise of the CMSA for academics to collectively examine their candidates.

National unitary examinations are considered International Best Practice for specialist examinations and assessment. They are used in many countries such as Pakistan, USA, and Canada. Some regions even have multinational unitary examinations such as Europe, Australia, and New Zealand. Other examples of multinational examinations include the West African College of Surgeons, and the West African College of Physicians that have single exit examinations that span >20 West African countries, and the College of Surgeons of Eastern, Central and Southern Africa (COSECSA) and other ECSA Colleges whose specialist examinations include >15 countries.

Benefits of the CMSA’s national unitary examinations include:

• Ensures national standards and quality assurance.
• Allows universities to set national curricula and maintain national standards for specialist training.
• Permits standard setting of examinations to ensure consistent levels of difficulty.
• Are a significant resource saver for universities and their staff and affords economies of scale and consolidation of expertise in examination administration.
• Allows for development of national question banks rather than for each university needing to develop its own SBA and structured oral examination question banks.
• Supports smaller, understaffed training units whose overstretched specialists cannot be reasonably expected to effectively run a clinical service, teach and train under- and postgraduates, and still set their own multiple-choice examinations, and run specialist examinations.
• Economies of scale mean that candidates are advantaged by having examinations twice a year.
• Save precious time and expense as 10 external examiners, one for each university, do not have to be sourced.
• Protects candidates from victimization or favouritism by their local superiors.
• Protects candidates from lesser advantaged institutions being stigmatised by passing the same national examination as their peers.

• The CMSA is committed to non-racism and transformation of the specialist workforce and does not tolerate racial discrimination or victimization. The CMSA has a robust system to guard against discrimination and to address any concerns about discrimination.
• Candidates’ names are not revealed to examiners in written or oral examinations, only candidate numbers.
• Structured oral examinations are marked against memoranda, which mitigates unconscious bias.
• Examiner panels, moderators and conveners are multiracial.
• The CMSA investigates allegations of misconduct in accordance with its guidelines and regulations.
• The CMSA has a whistleblower’s portal where submissions can be made anonymously.
• An aggrieved candidate may provide details to the CMSA, who conduct full investigations.
• The CMSA records all structured oral examinations; recordings are independently reviewed should there be allegations of bias, including of racial discrimination, or examiner misconduct.
• Part of the mandate of the CMSA’s Social and Ethics Committee is to review any unethical practices, including racial discrimination.

• It is universal practice that university professors and academics examine in specialist examinations.
• Candidates do not engage with their own superiors only, as there is representation from all training universities in the examinations and on the examination committees.
• Questions are sourced from all universities.
• In structured oral examinations, there are multiple examiners and each exam station is independently marked, any positive or negative influence of having one’s own professors as an examiner is diluted.
• Having a national unitary examination with examiners drawn from all over South Africa protects candidates from victimization or favouritism by their immediate superiors.
• All examiners work in teaching hospitals and are therefore well versed with the training environment to contextualise assessments.
• Having a CMSA national unitary exams ensures a nationally agreed standard for candidates.

• Candidates are advised of assessment formats, as well as about appeals and remarking processes, via the CMSA website, national candidates’ webinars and by their individual colleges.
• Allocation of marks is transparent.
• In line with international best practice, and to improve fairness of the examinations, the CMSA has moved away from traditional long answer questions to using Single Best Answer (SBA) and Short Answer Questions (SAQ), and from unstructured patient based clinical examinations to structured clinical examinations with memoranda.
• Each college council appoints a convenor, moderator and 5-25 examiners for every exam, selected to ensure university, gender and racial representation as best possible.
• The examination processes are overseen by the constituent college, the Examination and Credentials Committee (ECC) and the CMSA Senate.
• Moderators are experienced professors within the speciality to ensure fairness of examination and assessment of individual candidates, and consistency in marking processes.
• The CMSA has various processes that allow unforeseen circumstances to be taken account and be considered for moderation. This includes feedback from examiners, examination centres and candidates. All this is captured in a database that is reviewed in the first instance by the Academic Registrar and Executive Director: Education and Assessment and as needed by the Examiners, the Constituent College and the Examinations and Credentials Committee and necessary adjustments are made.
• Standardisation and standard setting are used to ensure fairness.

• Standard setting represents international best practice.
• Standard setting standardizes the levels of difficulty of examinations across examination cycles.
• It therefore improves the fairness of examinations and hence benefits candidates who may otherwise have been disadvantaged by a more difficult examination.
• It maintains standards and protects the public from substandard specialists who may have passed an easier examination.

• The CMSA is transparent with its examination processes.
• Unsuccessful candidates receive a feedback report that details where they went wrong.
• Candidates are given a breakdown of their marks.
• Candidates can identify where they performed poorly and return to their training institution to discuss how to fill identified knowledge gaps.
• Candidates may engage the CMSA and their constituent college.
• Candidates cannot however view SBA questions for the CMSA to protect the integrity of its question banks.

• The CMSA has multipronged engagement opportunities for candidates, in addition to the comprehensive candidates’ packs shared with candidates.
• The CMSA provides full briefings of the entire examination process and fields questions from candidates at the National Candidates’ Webinars.
• After the examination, candidates engage through the complaints and appeals system.
• Specific CMSA staff are allocated to candidates of each college.
• Candidates have direct access to the Academic Registrar and the Constituent College Presidents and Secretaries; the CMSA encourages such access.
• Candidates can email the Academic Registrar about concerns about examinations or simply book an online appointment with the Academic Registrar on her open days.
• Concerns are considered at the Management Committee Meetings of the ECC.
• The cell phone number of the CEO is listed on the CMSA website.
• Candidates, stakeholders, examiners etc are encouraged to engage with the CMSA Praesidium on any matter and frequently do so.
• The leadership of the CMSA meets annually with registrars alongside each of the 5 regional admission ceremonies in Bloemfontein, Cape Town, Durban, Gauteng, and Mthatha
• Registrars are represented on governance structures of constituent colleges through discipline specific bodies and/or the South African Registrars Association (SARA).
• The CMSA has bilateral standing meetings with registrar groupings (SARA, SAMATU).
• The CMSA has a Young Specialists Forum to improve engagement with younger specialists and trainees.

The CMSA has well-regulated appeal processes that are transparent, are publicly available on the CMSA website and are in line with international best practice.

• The CMSA is not-for-profit and does not profit from examination fees. In fact, the exam fees do not cover the full cost of the exams and costs are currently cross subsidised by CMSA membership fees.
• Examiners, moderators, conveners, and elected leadership of the CMSA provide their services unpaid to minimize costs to candidates.
• The CMSA pays its staff at public sector salary scales and has tight cost controls.
• By offering decentralised examinations in 8 centres in South Africa, candidates no longer pay for travel and accommodation, saving candidates an average of R10000 in expenses and they do not need to take additional leave.
• CMSA’s examinations are not expensive when compared to global counterparts if the final examination fee is calculated as a percentage of annual salary.

• Candidates are signed off by their university as being clinically competent prior to being admitted to the CMSA’s Fellowship exit examination.
• This complies with the separation of assessments of clinical competence at training institutions, assessment of theoretical knowledge by a written CMSA examinations (SBA or short answer questions), and assessment of clinical reasoning and complex decision making by online CMSA clinical examinations.
• Assessment of each of these components – clinical competence; knowledge; and clinical reasoning and decision making, are separate competencies, and candidates must pass each of these 3 components.
• The Fellowship is a national exam; a local mark for clinical competence cannot constitute part of a national examination mark.
• Workplace based assessment (WBA) is being phased in by the universities as a more effective and validated way of supporting learning and assessing clinical competence.

WBA is considered international best practice for assessing clinical competence in the workplace and ensures that specialist trainees are clinically competent before being permitted to write the CMSA exit examination. It involves candidates being continually assessed at their training institution to evaluate progression through the specialty training programme as well as identifying their learning needs. WBA is being developed by a National WBA Task Team under the auspices of SACOMD. The CMSA is simply assisting in an advisory capacity. It is being phased in nationally at all universities over the next few years.