The Combined Training Program in Child and Adolescent Psychiatry, Pediatrics, and Psychiatry (Triple Board Program) began training the first residents in 1986 at six sites: Albert Einstein College of Medicine, Brown University Program in Medicine, University of Kentucky College of Medicine, Mount Sinai School of Medicine, Tufts University School of Medicine, and University of Utah School of Medicine. It began as a pilot project with the support of over 11 professional organizations including the American Board of Pediatrics (ABP) and the American Board of Psychiatry and Neurology (ABPN) and was originally titled the Pediatric-Psychiatry-Child Psychiatry Pilot Project (1–3). I had the good fortune of being in the first class of the triple board residency and graduated from the Brown University School of Medicine triple board residency in 1991. As new portals into child and adolescent psychiatry training are being developed and new pioneers are trained, this article is a reflection of my own professional journey as one of the pioneers of the triple board program.
I chose the triple board program for several reasons. I had a desire to train in both psychiatry and pediatrics, I wanted to participate in a new endeavor, and the brain/mind was an untapped frontier and thus the future held the promise of new discovery. Additionally, the mind/body connection intrigued me, more than one professional option at the end of training was appealing, and my experience in medical school was very positive in both pediatrics and adolescent psychiatry.
As one of the “pioneer” residents, my training was far different from triple board residency experiences today. A significant portion of my residency was spent helping the program evolve; building on the strengths of the individual departments, aiding with interdepartmental communication, “proving” the program was viable, and reconfiguring the basic structure of the program. Thus, part of my education was spent learning systems issues in addition to my multiple roles as pediatrician, psychiatrist, and child psychiatrist. Being in the first graduating class also afforded me wonderful mentoring both during my residency and beyond.
Unique opportunities arose because of my status as a triple board resident. I participated in collaborative office rounds sponsored by Maternal Child Health, whose goal was to increase communication between child mental health providers and pediatricians. I carried the collaborative office round model with me to each professional site in which I worked since graduation. I could only have continued this model because of my experience at Brown and my dual roles of pediatrician and child psychiatrist.
As I and the other pioneers finished our training, there was speculation about our identities. Did we see ourselves as a “new breed,” with a morning pediatric clinic followed by an afternoon of psychotherapy and medications? Or would we follow in the more traditional models? Were we all to be researchers working at the interface of pediatrics and child psychiatry?
I did not know how to decide a career path while both finishing a novel, integrated program and feeling “unfinished” in my professional development. I relied on the advice of mentors. I knew I wanted to work at the interface of pediatrics and child psychiatry and I was steered toward academic institutions where there was a strong commitment to pediatric psychiatry. Thus I considered consultation-liaison positions, positions at programs with pediatric medical psychiatry units, and a research fellowship. It was gratifying and reassuring to learn that I would be marketable at graduation. Warren et al. (4) described outcome measures of triple board program graduates from 1991–2003, and reported success in terms of career outcomes, involvement in academics, and “graduate reported satisfaction.” (It must also be noted that with respect to “marketability” 2% of graduates were “unemployed by choice” as reported by Schowalter in 2002.)
I decided to remain in Providence to develop an inpatient pediatric psychiatry unit and to join the faculty at Brown University School of Medicine. My decision was based on a number of factors, including the opportunity to start a novel program, to continue working with established faculty mentors, and to work in a community I had grown to love.
When I finished my training in 1991, child psychiatry in the United States was a vastly different profession than it is today. Fluoxetine was the only approved SSRI for treatment of depression of adults (sertraline was approved later in 1991), and medication use in children was limited. Managed care was only just beginning and Rhode Island was a state with early high penetration of managed care. With my triple board training, I served as the medical/psychiatric attending for the children admitted to my inpatient service. Having completed an integrated program, I was unprepared to answer the questions of the managed care reviewer. Splitting benefits into different pots of “medical versus mental health” had just begun. As I was developing a program for children with combined, complex medical and psychiatric conditions, I was forced to address the question: “Is it medical or is it psychiatric?” It was ironic to be the product of an integrated program with my own blurred identity while insurers were preventing us from considering the “whole” child.
My roles at Brown included directing a pediatric psychopharmacology clinic and team teaching a course in human development to first-year medical students. Triple board program graduates are well-trained to teach such a class. Establishing research was also part of my faculty identity at Brown. I was interested in two particular areas of research: somatoform disorders—especially unexplained physical complaints and excessive use of the health care system—and psychoneuroimmunology. Both areas were difficult to pursue in the pediatric population and eventually I narrowed my focus to the “high utilizers” of the pediatric health care system.
Personal life changes led to me leave Brown in 1997 and move north of Boston. Since leaving Brown, I have worked in New Hampshire and Massachusetts and am now the child psychiatry residency training director at Maine Medical Center in Portland. In each position, although primarily functioning as a child psychiatrist, I lobbied to have either a liaison or educational role with pediatricians. I feel uniquely trained for that role as I am also a pediatrician, and I find that initiating variants of the original collaborative office rounds model in each setting has been fun and gratifying. As work force shortage issues continue—child mental health services are especially scarce in Maine—establishing collaborative care consultative models with pediatricians is essential and triple board graduates have special qualifications to participate in such models.
In Massachusetts I was one of the original child psychiatrists in the northeast region on the Massachusetts Child Psychiatry Access Project (MCPAP). The MCPAP is an innovative project utilizing child psychiatrists regionally to work in a collaborative/consultative role with pediatricians and other primary care physicians. The goal is to ensure that the mental health needs of children in Massachusetts are better met. Triple board graduates are well prepared for such innovative programs. In Maine we are exploring collaborative care models to be incorporated into training both psychiatric and primary care residents.
When the opportunity arose to return to academic child psychiatry as the training director at Maine Medical Center, I chose to make the transition. In many ways, I am well qualified; I have previously worked in academic child psychiatry, but I have also executed the role of a child psychiatrist in the community. My training in pediatrics has aided me in maintaining strong ties with pediatricians. As one of the “pioneers,” I feel my training in systems issues and interdepartmental communication is invaluable in the role of training director.
There is a critical shortage of child and adolescent psychiatrists (5), and this problem was not ameliorated with the triple board program. A new innovative training program, the Post-Pediatric Psychiatry Portal, has been created (6). From my experience as an “integrated training pioneer,” I propose the following core essentials for institutions planning to participate in the Post-Pediatric Psychiatry Portal: (a) positive interdepartmental relationships between child psychiatry and general psychiatry, (b) that the structure of the two training programs allows easy integration, (c) triple-boarded faculty who can serve as mentors, and (d) a foundation of interdepartmental collaboration between child psychiatry and pediatrics.
In summary, when asked “would you do it again?” I honestly do not know the answer. There were many benefits I reaped from being in the first graduating class of the triple board program, but being the first was hard work. I think most programs have built on the strengths of each individual department to enhance the educational process in a positive longitudinal fashion. Mentorship for triple board residents is essential, both during training and in the postgraduate years. Being a graduate of a triple board residency program affords many professional opportunities from blended practices of pediatrics and psychiatry, research fellowships, academic positions, and traditional independent practice.
At the time of submission, the author disclosed no competing interests.