Neurosurgical training in Ireland fosters personal, professional growth

Ralph Dacey Jr., MD, head of the Department of Neurological Surgery at Washington University, and Chester Yarbrough, MD, chief resident in neurosurgery, pause before a recent surgery at Barnes-Jewish Hospital. (Credit: Robert Boston)

Through an elective rotation that began nearly 15 years ago, neurosurgery residents at Washington University School of Medicine have an opportunity to see how complex neurosurgical procedures are performed in another country with a markedly different health-care system.

The residents who participate in the six-month program travel to Dublin in their sixth year of training to work at Beaumont Hospital and, some of them, the affiliated Temple Street Children’s Hospital. The hospitals are part of an academic medical center and are major referral sites for neurosurgery cases.

Ralph Dacey Jr., MD, the Henry G. & Edith R. Schwartz Professor and head of the Department of Neurological Surgery, said the rotation shapes residents in several ways, exposing them to different instruments and techniques in the operating room, giving them a high level of responsibility, and introducing them to a different health-care system. In Ireland, free health care is provided to the public, with higher levels of coverage for those with the lowest incomes. To cut down on waits, however, many people in Ireland pay for private health insurance.

“Functioning in a totally different system, they learn the essential elements of our specialty and what aspects of care may be of lower value,” said Dacey, who initiated the program in 2000. “They realize the strengths of our system and the strengths of alternative systems and become more prudent stewards of resources in our country.

“Residents also assume a high degree of responsibility on the neurosurgical service. They grow as surgeons and clinicians because of that added responsibility.”

Chester Yarbrough, MD, chief resident in neurosurgery at Washington University, completed a rotation at Beaumont Hospital and Temple Street Children’s Hospital in 2014. He worked under two neurosurgeons who made sure he was exposed to many types of cases.

Most of the cases Yarbrough worked on were at the children’s hospital and ranged from pediatric spinal cord and intracranial tumors to treatment of craniosynostosis (abnormal head shape), hydrocephalus and trauma.

Among the differences he noted was an increase in surgeries involving spina bifida. “There are many more women who give birth to babies with prenatal diagnoses of spina bifida,” explained Yarbrough, whose focus at Washington University is vascular and oncological neurosurgery. “We operated on many more such patients in Ireland than I would see in a similar time period here.”

Another difference he noted was in the treatment of craniosynostosis. The condition results when there is fusion across one or more of the areas that typically separate bones in the skull. This can cause secondary deformities in the shape of the skull and can lead to elevated intracranial pressure.

In Ireland, surgery to repair the condition is only performed at the children’s hospital, where Yarbrough did the brunt of his work. There, the condition is most often repaired with a craniotomy, surgery that requires a large incision and considerable manipulation of the skull bones.

In the United States, children with craniosynostosis most often are treated with minimally invasive endoscopic techniques aimed at releasing the skull bones, followed by postoperative treatments to achieve sought-after corrections.

“Both approaches are well-supported by the evidence, and there are advantages to each,” Yarbrough said. “The telling point is how the patients look and develop years down the line.“

In his time in Ireland, Yarbrough also operated on about 30 patients with brain tumors. He found the Irish use some different instruments than are used in the U.S. He picked up a few tricks and techniques he believes will help him in cranial procedures in the future. And he gained skills in trauma management he feels definitely will help him. The hospital where he worked is the only children’s hospital in the country that operates on patients with brain trauma, he said.

Ralph Dacey Jr., MD, meets with the U.S. ambassador to Ireland, Kevin O’Malley, at a reception in Dublin to recognize the relationship between Washington University and neurosurgeons in Ireland. (Credit: Courtesy of R. Dacey)

Washington University’s involvement in and support of the program has forged a bond between Dacey and Ireland’s top medical establishment. That working relationship contributed in 2013 to him being awarded an Honorary Fellowship of the Royal College of Surgeons in Ireland.

And this year, a delegation from the neurosurgery attended a reception hosted by the U.S. ambassador to Ireland, Kevin O’Malley, a St. Louis native. O’Malley held the reception at the U.S. Ambassador’s residence in Dublin’s Phoenix Park to recognize the long-standing educational relationship between the Irish neurosurgeons and Washington University.

The department’s delegation included Dacey, Gregory J. Zipfel, MD, associate professor of neurological surgery, and David D. Limbrick Jr., MD, PhD, associate professor of neurological surgery.

“The experiences of our residents in Dublin have a lasting impact on their lives as people and as surgeons,” Dacey said at the reception. “They learn some humility as they recognize the great skill and compassion of Ireland’s neurosurgeons, physicians, radiologists, nurses, therapists and hospital administrators.”

Yarbrough has stayed in contact with the consulting neurosurgeons and staff at Beaumont and Temple Street hospitals.

“The relationships we gained are great,” he said. “It was a wonderful experience, personally and professionally.”

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