An Coiste Feabhais Acadúil
The Committee on Academic Quality Improvement
The Academic Quality Assurance Programme 2004 - 2005
REVIEW OF
DEPARTMENT OF SURGERY
FINAL REPORT
3 June 2005
1
Department of Surgery: Review Report 2004–05
This report arises from a visit by a review team to the Department of Surgery at NUI
Galway on 28the February and 1 March 2005. The Department had already prepared
and submitted a ‘Self Assessment Report’ that, with other documentation, was made
available to the review team well in advance of the visit.
The review team consisted of: Professor David George, Regis Professor of
Surgery, University of Glasgow (Chairperson); Dr Ruth Barrington, Chief Executive
Health Research Board-An Bord Taighde Sláinte; Professor Gerald O’Sullivan,
Professor of Surgery, Mercy Hospital, Cork; Professor Gerard Loftus, Department of
Paediatrics, Clinical Science Institute, NUI Galway; and Seosamh Mac Donnacha,
Comhordaitheoir Acadúil, Acadamh na hOllscolaíochta Gaeilge, acting as
Rapporteur. The report is structured covering the following topics:
Introduction
1.
Aims and Objectives
2.
Organization and Management
3.
Programmes and Instruction
4.
Scholarship and Research
5.
Community Service and The Wider Context
6.
Summary and Concluding Remarks
Introduction
The Review Group would like to thank all members of the Department for their warm
welcome and their enthusiastic participation in the review process.
The Review Group recognises that there have been inevitable difficulties for
the Department in the inter regnum between Professor Given leaving and Professor
Kerin taking up his post only six months ago. Equally the Review Group recognises
the considerable impact that Professor Kerin has already made in Departmental
development and feels that this is reflected in the clear commitment and enthusiasm
demonstrated by all members of departmental staff.
The Department is part of the Faculty of Medicine and Health Sciences. The
Department itself is difficult to define as it is multi-faceted and based on more than
one site. In addition to its core academic staff, the Department depends on the
specialist surgical staff of University College Hospital Galway, Merlin Park Hospital
and the staff of affiliated hospitals such as Castlebar General Hospital, for practical
surgical instruction. The Review Group has therefore distinguished in its review
between the core University Department and the wider department of surgical
specialists in general surgery, orthopaedics, urology, breast, vascular, accident and
emergency, plastic surgery, in the hospitals mentioned above.
With regard to the core department, the Review Group welcomes the increased
input and support from the University in terms of the upcoming appointment of a new
Senior Lecturer and a new Director of Laboratory Research. The Review Group is
also very supportive of the appointments of chairs in radiology and anaesthesia, and
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Department of Surgery: Review Report 2004–05
new senior lecturer posts in ENT, ophthalmology and orthopaedics. It is to be hoped
that further academic appointments will follow in due course.
Because of the disparate nature of the wider Department of Surgery, the
Review Group has sought to concentrate on areas to improve cohesion in both
education and research. Many of these issues relate to the planning and delivery of
teaching while others relate to research issues and research facilities that are common
to all disciplines.
The Review Group recognises the enormous contributions made to teaching
and research by consultants in all disciplines and encourages the University and the
Faculty of Health Sciences to forge stronger links with University College Hospital
Galway in particular, to formalise the relationship between academic staff and the
clinical specialists whose input is such an important part of the clinical teaching of
students. The Review Group understands that a Faculty group is exploring the
potential for professional advancement by clinical specialists within honorary
University posts in recognition of distinction in both teaching and research and
recognises that this could be an important part of establishing a more formal
relationship between the Faculty and clinical specialists.
1. Aims, objectives and planning
The Review Group considers that the aims of the Department of Surgery as set out in
the self-assessment report are appropriate. However, these aims and objectives should
be more explicitly linked with the aims and objectives of the Faculty and of the
University. The ownership of the aims and objectives of the Department could be
shared more with those involved with the Department.
The Department should have a strategic five year plan setting out how it will
deliver on its teaching and research aims and objectives as well as its contribution to
the faculty and the University. The strategic plan should address how to facilitate and
formalize the increasing involvement of consultant staff in the teaching and affiliated
hospitals in the undergraduate and postgraduate teaching and research activities of the
Department, through opportunities for academic advancement and other means. The
strategic plan should address how the Department can increase its links with basic
science and resources for research represented by the REMEDI Centre for Science
Engineering and Technology funded by Science Foundation Ireland and the National
Centre for Biomedical Engineering Science. The strategic plan should also identify
the critical indicators of success of the Department such as the success of graduates in
Irish and international medicine, the ability to attract good staff, the number of
undergraduates applying to do research in the Department. It should also provide for a
means of collecting this information.
2. Organization and Management
As a result of the inter regnum period and the relatively recent appointment of
Professor Kerin, the Department is currently in the process of simultaneously
reviewing and developing both its strategy for going forward and the organizational
and management structures it will need to effectively implement its teaching and
research activities into the future. Within this context the Review Group recognizes
that the development of an enhanced academic management structure will be
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Department of Surgery: Review Report 2004–05
facilitated by and is predicated on a number of further senior academic appointments
in the areas of anaesthesia, ENT, ophthalmology and orthopaedics. The Review
Group recommends that this be used as an opportunity to review and clarify the roles
and responsibility of each member of the academic, administrative, clinical and
support staff of the Department in ensuring the quality of delivery of its teaching and
research activities.
In tandem with the above appointments, the Review Group recommends the
establishment of an Academic Committee comprised of the academic leaders in the
various disciplines within the core and wider Department and other individuals as
appropriate, with a view to facilitating the integration of the Department’s teaching
activities with those of the broader Faculty of Medicine.
The Review Group recommends that this academic committee also have a role
in:
•
planning the development of a consistent approach to the development and
delivery of teaching programmes, as proposed at 3.2.1 below;
•
facilitating the enhancement and further dissemination of best practice
approaches which already exist within the Department, particularly in relation
to the management of tutorials and attachments;
•
facilitating the development of an integrated and managed curriculum across
the sub-disciplines within the Department;
•
facilitating an iterative review of course objectives and the attainment of
course objectives, with a view to enhancing the overall student experience.
•
facilitating and providing opportunities for staff members who wish to
increase their commitment to the educational aspects of the Department’s
work, with the aim of developing medical education and education research as
an area of expertise within its own right, within the Department;
•
ensuring that the teaching skills of staff develop in line with their clinical
skills; the Review Group was impressed by the resources offered by CELT for
this purpose.
• setting the quality agenda for teaching.
A key issue facing the Department is the vagueness that surrounds the teaching
commitments of clinical specialists in University College Hospital Galway and Merlin
Park Hospital who are employed by Health Service Executive (HSE). Although a
teaching commitment is included in their contracts, the nature of this commitment is
not specified. The Review Group recommends that the University and Faculty
clarify this issue with hospital or HSE management in the form of a clearer statement
of the teaching commitments of such staff when appointed to teaching hospitals. This
could take the form of a Memorandum of Understanding between the HSE/hospital
management and the University.
There appears to be a certain lack of agreement about the participation of the
Department of Surgery in the curriculum review structures of the Faculty of Medicine
and Health Sciences. The Review Group recommends that because of the importance
of surgery to the undergraduate programme the Department should be represented on
the Faculty committee that is currently reviewing the medical curriculum.
The Review Group recognises that good informal relationships exist within the
Department and as the management structures referred to above develop the Review
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Groups recommends the development of more formal processes for involving all staff
in the strategic direction of the Department.
3. Programmes and Instruction
3.1 General
The academic Department of Surgery has a responsibility for delivering
undergraduate education in surgery as part of the MB, BCh, and BAO 6 year
undergraduate programme. The Department also has a role in facilitating students
pursuing a MCh and MD by research. The Master of Medical Science programme is
provided by a number of departments including surgery, and students may undertake a
research thesis/dissertation in a surgical discipline, which will be the responsibility of
the Department of Surgery.
In judging the academic Department of Surgery according to the formal
criteria set out in the academic quality review guidelines, the Review Group was very
conscious that the leadership of the Department has only recently changed, after a
prolonged inter regnum. Accordingly, comments of the Review Group should be
viewed more as a signpost to the future rather than a criticism of the existing
Department, which is in a phase of rapid evolution and development.
The delivery of undergraduate education in surgery is based to a large extent
on good will and tradition. Though the academic Department of Surgery has been
strengthened in recent years, the majority of the clinical teaching still falls to
consultants and NCHDs who have only a loose affiliation with the University. In
spite of many logistic, organisational and time tabling difficulties (identified by staff
and students who met the Review Group) the Department has managed to deliver a
good standard of surgical undergraduate education, and graduates have a fine record
of achievement. Nevertheless there are areas that could clearly be improved without
major investment of resources.
3.2 MB, BCh, BAO
3.2.1 General
NUI Galway currently delivers a conventional 6 year undergraduate programme
leading to the degree MB, BAO, BCh. Students first interact with the Department of
Surgery at the end of their third year, throughout the fourth year, and again in the final
year. The teaching programme is a mixture of didactic lectures, small group tutorials,
bedside teaching, attendance at seminars and conferences, along with traditional
apprenticeship learning by attendance at ward rounds, outpatients, and operating
theatre. Over the period of engagement with the Department of Surgery, students are
rotated through a number of surgical disciplines and in addition undertake a summer
elective at the end of the fifth medical year (which may include surgery), and a junior
internship in the second term of final medicine with a further four weeks in surgery.
The Department attempts to ensure that all students get fairly even exposure to
general surgery and the subspecialties that are available in Galway.
Students are evaluated by continuous assessment, periodic examinations, and a final
exit examination in the summer of the final year with a written paper, clinicals and
oral examinations.
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The Review Group felt that the student experience could be enhanced by the
following measures.
(i)
A written curriculum with a clear indication to students as to the breath
and depth of knowledge that is necessary.
(ii)
Clear linkage between the examination process and the prescribed
curriculum.
(iii) An exploration of varying teaching methodologies, and an examination of
the components of the existing teaching programme to evaluate the value
to student learning of the various aspects of the students’ placements.
(iv)
Encouragement of uptake of teacher training programmes by those
involved in clinical teaching.
(v)
Structured, regular feedback from students, recent graduates, and
consultants supervising interns. These inputs should be used for ongoing
curricular and examination revision.
(vi)
Provision of a clinical skills laboratory.
(vii) Review of the rotational “firm” attachments to ensure: even exposure to
the sub-specialities, avoidance of large numbers of students on
attachments, provision of explicit expectations of students, aims and
objectives of the attachment, and a timetable and contact person.
(viii) A log book with student information, a core curriculum, and space to
record teaching topics delivered.
(ix)
A mechanism by which students can, when possible, be given early
warning of impending lecture/tutorial cancellations and an appropriate
explanation.
3.2.2 Student Assessment Procedures.
The Review Group noted that whilst a proportion of marks are attached for continuous
assessment, much still depended on the final examination. The difficulties in
assigning marks for “firm” attachments may be addressed by providing pictorial
records of students, recording attendances, and assigning projects or case histories.
The failure rate in surgery is similar to that in other clinical disciplines, and students
failing have often a track record of difficulties in undergraduate examinations, which
may also be evident during their clinical attachments. Some form of intervention or
formative assessment may help in the early identification, and possible rehabilitation
of these students. It was noted that cultural and linguistic differences may create
difficulties for overseas students in the clinical disciplines. This is clearly a faculty–
wide issue.
In common with other medical schools and disciplines, the awarding of first
class honours is still a rarity; the Review Group believes that this should change. As
with all examination processes, those in surgery should be subject to periodic review
to ensure that they accurately discriminate between students with different levels of
knowledge, understanding and skills, and in particular ensure that graduates are safe
for clinical practice. Students and lecturers identified a tendency to mark clinical
placements in a way that did not sufficiently reward those students who made full use
of these learning opportunities. The Review Group recommends that better use be
made of the range of marks that may be awarded to the benefit of outstanding
students.
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Department of Surgery: Review Report 2004–05
3.2.3 MCh, MD
The Department has an established interest in breast cancer, and under the leadership
of Professor Kerin has ambitious ideas for further development in this area in
collaboration with the Departments of Pathology, Medicine, and the National Centre
for Biomedical Engineering, and REMEDI. The Department has research facilities in
the Clinical Science Institute, and will clearly develop synergies with the other
research groups in CSI and on campus. Acquisition of a higher degree appears to be a
prerequisite for entry onto specialist registrar schemes, so that there is a pool of
motivated medical graduates keen to undertake basic research. The Department will,
however, need to ensure ongoing quality assurance of projects, processes, and
assessment for these degrees.
3.3
Structuring Clinical Teaching
As noted in the Medical Council review following visitations to all the medical
schools in 2003, undergraduate medical education is seriously under resourced and all
the medical schools, including Galway, are heavily dependent on the fee income
provided by overseas students. The historically low unit costings for medicine were
facilitated by the provision of clinical teaching on the basis of tradition and good will,
and the economies of scale made possible by common teaching of medical and
undergraduate science students in the preclinical disciplines. In response to the
Medical Council, and developments in medical education worldwide, the critical role
of non-university staff for clinical teaching needs to be recognised, formalised and
secured. The Review Group noted that the university is attempting to devise an
academic promotion scheme for clinical lecturers, and supports the national strategy
of the medical school deans that all consultants appointed to teaching in affiliated
hospitals should have protected sessional time for teaching both undergraduates and
postgraduates.
4. Scholarship and Research
It is recognised that the Department of Surgery is currently undergoing redevelopment
but there are several encouraging features which suggest that productive, high quality
research programmes in surgery and related research are emerging.
•
The Professor of Surgery has a strong track record of achievement in breast cancer
research and has a declared commitment to establishing and fostering programmes
which are cross disciplinary, meaningful and career enhancing. His area of interest
is breast cancer and he should be given a lead role in cancer research in the
University thus ensuring a research continuum from laboratory to clinical
application. We noted the Dean’s strong support for this concept.
•
The University Hospital will become a supra-regional centre for cancer services
with all the major therapeutic facilities, including diverse surgical specialties,
radiotherapy and medical oncology, in place within a year. The regional centre for
Breast Check, the national breast screening programme, with data managing
facilities will be located in Galway. This will further consolidate cancer research
opportunities particularly in health services and clinical trials.
•
All members of the wider Department of Surgery have a strong background in
research with higher degrees by thesis and based on supplied CV summaries have
continued to publish albeit mainly on clinical matters. All members interviewed
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Department of Surgery: Review Report 2004–05
were positively disposed towards research experience either through direct
involvement or in a facilitatory role. This is an important human resource.
•
A senior lecturer in surgery will shortly be appointed – this will further strengthen
the research staff.
•
A director of laboratory sciences will be appointed to lead, teach and supervise
molecular based research.
•
There is currently a research laboratory within the Clinical Science building with
basic equipment and staffed by two part-time technicians. It is our impression that
this laboratory is too small for future needs. We believe, however that it is
important to maintain such a facility immediately adjacent to the hospital to
ensure maximal involvement by clinical staff. It was suggested to us that
amalgamation of laboratory facilities between specialties would lead to more
efficient usage of expensive equipment, less duplication and greater job
satisfaction for technical staff. The Review Group recommends that this concept
be explored further particularly with the Department of Pathology where there is a
commonality in research endeavours and an established close alliance with
surgery. We recognise that there may be issues for and against, notwithstanding
the need for facilities for diverse research endeavours.
•
There is a patient data, tissue and serum bank with over 15 years follow up. This
is a valuable resource and will permit immediate research related to disease stage,
responses etc.
•
A separate private source of breast cancer research funding is in place – the
National Breast Cancer Research Institute - guaranteeing continuity of research.
•
Closer linkage in research should be established between surgery and the other
funded research institutions within the University including the Departments of
Bio-Engineering, Regenerative medicine, and Biochemistry where there are many
areas of common interest. This would promote greater synergy and maximise
funding opportunities both at national and international levels. We note that some
alliances have been established particularly by vascular surgery, orthopaedic and
plastic surgery departments and bioengineering and regenerative medicine.
•
The student feedback on research experience was very positive – one of whom
secured an exchange with a laboratory in Berlin and achieved a publication. We
recommend that future student research programmes be more formal with
advertising of opportunities and use of established selection processes
The Review Group recommends that the Department establish a surgical research
committee to facilitate and stimulate areas of research in common across the
disciplines, including student involvement, molecular technologies, health service
provision, linkage with other research institutes locally and externally, standardisation
of requirements for postgraduate degrees, resource accountability and development of
ongoing research policy
5. Community Service and Activities in the Wider Context.
The previous professor, Professor Given established the National Breast Cancer
Research Institute in 1991. This is a voluntary organisation that raises funding for
clinical laboratory research. The Department of Surgery is an active participant in
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Department of Surgery: Review Report 2004–05
this enterprise and members of staff regularly give talks to women in the community.
The Department is also an active advocate for Breast Check Ireland and its expansion
to the West of Ireland. Staff of the breast unit also run a breast cancer information day
during the month of October which is breast cancer awareness month.
Mr. Oliver McAnena is the Regional Director of Cancer Services and is
actively involved in public discussion on the development of such services.
The Department participates in the faculty-wide open day for school-leavers
intent on a career in medicine. The Department if also very involved in the regional
network of affiliated hospitals in terms of teaching and planning. Members of the
Department also frequently provide lectures and seminars for local general
practitioners and they also liaise directly with local politicians in terms of health care
issues.
The Professor of Surgery has also been involved with the Chicago radio show
entitled “Good Morning Ireland” and through this medium has raised $150,000 which
was used to purchase new equipment for the breast unit in Galway.
The Department of Surgery collaborates closely with other departments in the
wider context of the University and through these and the activities outlined above
plays a full and active role within the community at large.
6.
Summary and Concluding Remarks
The Department of Surgery makes a considerable contribution to the University
through its teaching and research activities. Currently under new leadership, the
Department is going through a process of development that should involve both the
development of a strategy and vision for the future and the development of an
organizational structure having the capacity to deliver on that strategy and vision. The
Review Group hopes that our comments and recommendations will provide a useful
contribution to that process. In summary, our main recommendations are:
•
That the Department’s vision and development strategy be formalised into a five
year plan that will be more explicitly linked with the aims and objectives of the
Faculty of Medicine and Health Sciences and the University, and will outline how
the Department plans to deliver on its teaching and research aims and objectives.
•
The establishment of an Academic Committee comprised of the academic leaders
in the various disciplines within the Department, and that this committee have a
key role in setting the quality agenda for teaching and encourage the development
of medical education and education research as an area of expertise in its own
right within the Department.
•
That the Faculty and the University formalise the arrangements for clinical
teaching commitments of clinical/consultant staff in the teaching hospitals, with
hospital management/HSE.
•
The adoption of a more structured and managed approach to the delivery of the
Department’s teaching activities as outlined in section 3 above, with a view to
enhancing the overall student experience.
•
The establishment of a surgical research committee to facilitate and stimulate
areas of research in common across the disciplines.
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Department of Surgery: Review Report 2004–05
In conclusion, the Review Group wishes to praise the enthusiasm shown by the staff
with which we met and their commitment to achieving their vision of having a world
class department of surgery.
Comments on the Methodology of the Review Process
1. The Review Group found the interviews with students and members of the core
and wider Department most helpful. However, we would have welcomed an
opportunity to speak with non-EU students to hear of their experience and
representatives of all the surgical specialties associated with the Department.
2. The Review Group considers that the self-assessment report, while helpful, could
have been more analytic of the problems facing the Department and the process by
which it was drafted would have benefited from greater involvement by staff and
students of the Department.
3. The timetabling of the review was excellent.
Professor David George (Chairperson)
Dr Ruth Barrington
Professor Gerald O’Sullivan
Professor Gerard Loftus
An tUasal Seosamh Mac Donnacha
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