n the early 1980s, leaders in academic medicine were aware of a growing shortage of child and adolescent psychiatrists. The report, "Project Future," had documented a widening gap between the need for child mental health professionals and the projected supply (1). In addition, the medical specialties of child psychiatry and pediatrics had drifted apart. Despite the fact that child psychiatry had developed from pediatrics and many of the early leaders in child psychiatry were pediatricians, collaboration and referrals between the two specialties were often problematic. John Schowalter, M.D., regarded by many as the father of the triple board program, conceptualized the new approach to training as a way of addressing both problems.
The triple board program was designed to attract a new group of medical students into child psychiatry: those whose interests encompassed both the medical and psychological disorders of childhood. The goal was to train a hybrid physician with a legitimate identity and skill base as both a child psychiatrist and a pediatrician. Individuals so trained could create an enhanced academic presence within medical schools that would further attract students into child and adolescent psychiatry.
The founders of the triple board program realized that even if the new program was integrated and novel, it had to be shorter than the 7 or 8 years required to achieve board eligibility in pediatrics, general psychiatry, and child psychiatry via the conventional route. They proposed that a carefully designed curriculum could accomplish the combined training in 5 years, devoting 24 months to pediatrics, 18 months to general psychiatry, and 18 months to child psychiatry. Abbreviated and integrated training was a radical concept for organized medicine 25 years ago, and the path to approval by the relevant bodies—the residency review committees, American Board of Psychiatry and Neurology (ABPN), American Board of Pediatrics, American Academy of Pediatrics, and the American Academy of Child and Adolescent Psychiatry (AACAP)—was arduous. Ultimately, a 10-year pilot program was approved; 32 medical schools applied and six were chosen (Einstein, Brown University, Kentucky, Mount Sinai, Tufts, and Utah). The first residents entered these programs in 1986.
The National Institute for Mental Health (NIMH), Center for Mental Health Services, American Board of Pediatrics, and ABPN funded a comprehensive administrative and evaluative process during the pilot project (2). The Triple Board Program pilot project was deemed a success and concluded (two years early) in 1995 with the combined residency approved by the boards and opened to all medical schools. While the triple board programs are not independently accredited by the Accreditation Committee for Graduate Medical Education (ACGME), the residency review committees for psychiatry and for pediatrics accredit the categorical training programs involved with the triple board programs. New programs must be approved by the ABPN and American Board of Pediatrics and all three training components must be accredited and in good standing with the respective residency review committees (3). Since 1995, six new programs have opened and two have closed. Currently active programs are at Brown University, Cincinnati, Hawaii, Indiana, Kentucky, Mt. Sinai, Pittsburgh, Tufts, Tulane, and Utah, with 21 new positions available each year.
The triple board program has also been the model for other integrated psychiatry training programs that have subsequently been developed, including internal medicine-psychiatry, neurology-psychiatry, and family medicine-psychiatry.
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What is Involved in Triple Board Training?
While each program has developed an individual approach to educating the residents, triple board training includes a number of required elements. Most importantly, the curriculum must provide a cohesive training experience, rather than a "series of rotations among the specialties" (3). The individual curricula differ in the degree to which residents complete the specialties in large blocks of rotations or with each discipline interspersed throughout the 5 years. These variations across programs allow residencies to provide a curriculum that best matches the strengths of the training site, and allows applicants to identify the programs that best suit their individual learning styles.
In the 24 months of pediatrics, 50% of time is spent in ambulatory experiences, although residents also rotate through inpatient units and neonatal and pediatric intensive care settings. Triple board training provides opportunities for significant longitudinal experiences with patients. Residents provide primary care to a panel of pediatric patients over the entire course of their 5-year training. This means a resident may follow a child from the neonatal intensive care unit to kindergarten or from the beginning of high school to college.
Twelve Brown University graduates recently reflected upon their training in essay style responses to the question "How does your training impact your current practice?" (unpublished survey, available from MMG). Of these, seven who practice child psychiatry highlighted the importance of training in normal development. Several graduates who practice child psychiatry also highlighted the intensive care training as an important educational experience. One graduate responded, "The NICU is a place where I saw families in crisis and I learned to manage families in extreme crisis.…Learning how to manage the intensity of affect is important in a multitude of work settings. I did not understand until some years later that the great lessons in doctoring in the NICU apply to mental health."
General psychiatry in triple board training is the most condensed portion of the three specialties and has the fewest specific requirements. Eighteen months of triple board training are spent in general psychiatry, compared with 36 months in the categorical training programs. Residents spend at least 4 months on inpatient units and 6—9 months focused primarily on outpatient care. They treat patients in emergency rooms, in medical clinics, and in inpatient units, and may have community mental health and forensic experiences. Again, opportunities for longitudinal care are valued in this curriculum, and residents are required to provide weekly treatment of patients for at least 12 months. Depending on the individual patient’s needs and program’s curriculum, this long-term therapeutic relationship may extend as long as 4 years, longer than typically seen in categorical psychiatry programs.
Child psychiatry training, proportionately, is the least condensed component of triple board training. Residents spend 18 months in child psychiatry, compared with the 24 months of traditional fellowship training. Residents are expected to learn about child psychiatry and development from prenatal life through adolescence. Through their supervised treatment of children and families in medical, community, forensic, inpatient, and outpatient settings, triple board residents learn psychopharmacological and psychotherapeutic treatment modalities. A year-long longitudinal treatment of a patient in weekly psychotherapy is also required in child psychiatry training. Triple board graduates who practice primarily in pediatric settings place a high value on the interviewing skills and therapeutic alliances with patients during the general and child psychiatry portions of the triple board training.
While each component of the triple board training is important, graduates’ descriptions of their training suggest the experience is more than the sum of the parts. In the Brown University graduates’ reflections upon their training, adjectives such as "holistic," "integrated," "synergistic," and "biopsychosocial" were commonly used to describe the approach that graduates use with patients (unpublished questionnaires, available from MMG). Additionally, the graduates highlighted their ability to communicate across specialties as an important outcome of their training, regardless of their career choice, as was also reported in a published study of the triple board outcomes (2). One medical director at a teaching hospital put it this way: "I feel I can interact and relate to a broad range of pediatric care providers." Another child psychiatry attending reported that he is able to communicate effectively to pediatricians because he understands what they know and how the pediatric culture functions.
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Who Selects the Triple Program?
We have developed strong anecdotal impressions of individuals who are attracted to triple board training from many experiences: interviewing applicants for categorical pediatrics, general psychiatry, child and adolescent psychiatry, and for triple board programs; meetings with triple board residents; and meetings with training directors over the last 20 years. Although it is less evident now than at the outset of the new program, students who consider triple board residencies tend to have a pioneering spirit and an adventurous nature. The relative newness of the integrated training approach generally is seen as a plus; few triple board applicants would be described as "traditionalists." Most applicants have had mentors or other medical faculty members advise them pursuing triple board training ("you’ll be a jack of all trades and master of none"; "I’ve never heard of it—cannot be that good"; "why not just be a good psychiatrist or pediatrician?"), but continue to explore it nonetheless.
What seems to motivate most triple board applicants is a particular passion: to get ideal training that will thoroughly prepare them to make a unique contribution to the welfare of children and families. The nature of the passion is highly variable. Sometimes it is very specific: "My brother was autistic and I want to get the comprehensive training needed to treat the child with developmental disabilities"; "I was raised in a community of Polish immigrants and even though they were in a big American city, they did not get the care they needed. I want broad training, so I can be as helpful as possible to that community." Others see triple board training as the best foundation for subsequent research that integrates biological and psychological aspects, such as psychoimmunology, neuroimaging, or infant psychiatry. Triple board residents vary in their ultimate career aspirations and choices, but they seem to share a profound interest in pediatrics and child psychiatry; they cannot conceive of excluding either from their professional lives.
One of the reasons the triple board program seems successful in an abbreviated period may be because the residents work so hard during their 5 years. On average, they put in more hours per week than categorical residents in pediatrics, general psychiatry, or child psychiatry. This is a known fact in our program, a stated expectation in the interview process, and a daily experience during training. Thus medical students who choose triple board training tend to be undaunted by hard work—or sublimate these concerns to their other ambitions.
Triple board residents are seeking comprehensive, integrated training and thus they know they will be immersed in—and shift back and forth between—different medical cultures. The "cross-cultural" aspects of training attract them, and they usually have the social skills necessary to negotiate these cultural transitions.
To date, over 170 physicians have completed triple board training. In a published survey of residents who completed triple board training between 1991 and 2003, nearly all triple boarders reported spending most of their professional time practicing child and adolescent psychiatry, and just over half worked in academic settings (4). One-third of the graduates pursued further training. Additional child psychiatry training, public health/epidemiology, and infant psychiatry were most commonly represented, with 7%, 4%, and 3.5% of the 113 respondents training in each of these fields, respectively. Triple board graduates pursued a breadth of postgraduate training experiences. At least one graduate reported a training experience in each of the following specialties: neuroimaging, medical education, ECT, pediatrics emergency medicine, speech and language pathology, posttraumatic stress disorder, pediatrics critical care, business and administration, cultural psychiatry, pediatrics hematology/oncology, biopsychiatry, autism/anxiety/obsessive-compulsive disorders, and eating disorders. A more recent e-mail survey developed to create a national triple board database also reflected a broad range of clinical practice settings and clinical interests (unpublished survey, MMG). Respondents to that survey describe practicing in areas that include overlap of pediatrics and child psychiatry, such as consultation-liaison (6/53), developmental disabilities (6/53), and child abuse (7/53). With their interest in academic medicine, triple board graduates are also involved in training the next generation of triple boarders. In all but one of the current programs, a triple boarder is or has been a part of the training team, as a training director or associate training director.
At the end of their training, graduates are board-eligible in pediatrics, general psychiatry, and child and adolescent psychiatry. According to the 2003 survey, board pass rates have been at least as high as the general board examinees (4). Table 1
presents the pass rates of triple board examinees as reported in the 2003 survey compared with pass rates of board examinees. The rate of board certification of all triple board graduates is somewhat lower than of the examinees, partly due to the fact that it can take 4 years to successfully complete all three board examinations, and partly because not all triple board residents elect to take all three boards, especially excluding pediatrics (4). Of the respondents to Warren’s 2003 survey, slightly over one-third of triple board graduates were certified in all three boards and nearly three-quarters of graduates had passed at least two boards. Becoming triple board-certified requires significant investment. Even with successful completion of each component, it can take 4 years for graduates to complete all of the tests. Registration and travel costs to take all three boards in 2006 were at least $10,000 (5—7).
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Triple Board Contributions to the Field
Triple board graduates can be found in a number of leadership positions in the field. As mentioned above, many triple boarders remain in academic settings. At the 2006 AACAP meeting, two triple board graduates, Xavier Castellanos and Robert Findling, were honored for their achievements as nationally recognized leaders in attention deficit hyperactivity disorder, neuroimaging, and bipolar disorder, and many other graduates are leaders in other areas. Triple board graduates regularly present at the national meetings of both AACAP and the American Academy of Pediatrics. Triple board residents and graduates have also received multiple CATCH grants from the American Academy of Pediatrics to promote children’s access to medical care. While they represent a small proportion of AACAP members, graduates have been recipients of five AACAP Pilot Research Awards (1996—2006), six Presidential Scholarships (1997—2003), and one Rieger Service Program Award for Excellence (personal communication, AACAP, 2007). Additionally, at least 15 triple board graduates have received competitive federal grants from the National Institutes of Health.
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Impact on the Sponsoring Medical Schools
Not only does a triple board program shape the development of the residents it trains, the existence of the program and the presence of a cohort of residents who span departments affect the institution. Based on our observations and experiences, to establish a triple board program, the departments of pediatrics, psychiatry, and child psychiatry must initially have at least a theoretical appreciation of integrated training and a willingness to work together (factors that also explain the relative scarcity of triple board programs). The situation may be conceptualized as analogous to a couple who imagine they want to have children together and then learn that actually being effective parents is a different challenge altogether.
In general, those institutions with successful triple board programs note a high level of cooperation and compromise between the involved departments. Initial goodwill combined with inevitable ambivalence must evolve into strong, respectful relationships between leaders and key faculty of each participating department—or else the program will fail. The day-to-day challenges involved in running a compressed integrated program are substantial. Scheduling is complicated, curricular modifications are required, and selection and evaluation processes must be standardized across disparate programs and rotations. Triple board residents tend to be assertive as individuals and cohesive as a group, so participating departments find that their internal difficulties are known by their sister departments to a much greater degree than before the triple board era.
The comfortable working relationships that develop between faculty in the participating departments as a result of making the triple board program work often translate into creative new clinical programs or research projects. At Brown, for example, our thriving pediatric-psychiatry partial hospitalization program has a pediatrician and a child psychiatrist as codirectors as does our forensic service that provides comprehensive medical and mental health services to the juvenile justice facility. NIH-funded research projects dealing with asthma, obesity, HIV, gastrointestinal disease, emergency psychiatry, and chronic pediatric illness in the family are all jointly led by investigators in both child psychiatry and pediatrics—triple board residents themselves have been described as "pollen carriers" who informally keep their attendings aware of activities and interests of faculty in the other departments.
Less tangibly, most (though never all) faculty involved with mature triple board programs are enthusiastic overall. They find the interdisciplinary clinical perspective stimulating; they like the easy access to "corridor consultations" that comes with the new, cross-departmental relationships; and they enjoy being part of a creative innovation in medical education.
A remarkable fact is that, until the recent entry by the University of Pittsburgh, no triple board program has been based in a "top 10" medical school, although most reside in strong clinical programs (8, 9). The factors behind that pattern are only speculative, but may include: highly subscribed residencies are less motivated to be innovative, as they likely recruit the residents they want to train; extremely successful and competitive faculty at such institutions are not prone to educational compromise, such as that which comes with combined training programs; top tier medical schools tend to be older and have more ingrained traditions, so change comes harder; and pediatric programs at such institutions may not want to invest in training residents who are likely to practice child psychiatry.
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The Future of Triple Board Training
Over 20 years after its development, the triple board training program is a well-established model for training a unique group of child and family physicians. The success of individual graduates and of the collaboration among departments at the triple board universities provides support for the concept that physicians, families, and academic departments all benefit from integrated training programs. In 2003, a national triple board organization was formed. The group has defined a triple board mission statement highlighting the goal of training residents to be prepared to provide clinical care, education, advocacy, public policy, and research using "a developmentally informed biopsychosocial approach to health, illness, and prevention" (10). Additionally, the group has developed a website to describe triple board to new medical students (www.tripleboard.org). The current triple board training directors are committed to supporting the development of new programs, especially in parts of the country that do not have triple board training programs, such as California.
In part because of the success of the triple board programs, AACAP has worked with the American Board of Psychiatry and Neurology and the American Board of Pediatrics to develop a new model of training. The new program, dubbed the Post Pediatrics Portal Project allows board eligible pediatricians interested in child psychiatry to enter a 3-year combined adult and child psychiatry training program. This variant of the triple board program increases the opportunities for pediatricians interested in providing more comprehensive biopsychosocial care of children and families and may also begin to address the significant shortage of child mental health providers in the United States (11). It is expected that this alternative pathway will engage additional pediatrically minded physicians in attending to children’s mental health. The first program accepted residents in 2007 and there are currently three approved programs at Case Western Reserve University, Creighton University/University of Nebraska, and Children’s Hospital of Philadelphia. Although similar to the triple board in content, the timing of entry into psychiatry training is sufficiently different that it is not expected to compete with existing triple board programs for applicants. As the triple board and the expanded triple board portal to child psychiatry training continue to grow and produce specialty trained physicians who work in community and academic settings, their "pollen carrying" tendencies may serve to increase children’s access to pediatric and psychiatric care that is intradisciplinary, coordinated, and of the highest clinical standards.