As director of a child psychiatry consultation liaison service I regularly work with medically ill children, grieving parents, and depressed adolescents in a pediatric hospital. Without a doubt, my job is at the crossroads of pediatrics and child psychiatry. Therefore, it is no surprise that I greatly value having received board certification in three specialties: pediatrics, general psychiatry, and child psychiatry. I believe that such a background would be meaningful to anyone who practices psychiatry today. While it might be assumed that it is the fund of knowledge that is of greatest worth, it is actually the process—the experience—of the three residencies that I treasure most. Each residency has provided me with a unique perspective. The integration of my experience in three distinct residencies affects the way I practice medicine.
Like most physicians who receive certification in three specialties but are not graduates from a special triple board training program, my career pathway twisted, turned, and evolved between a variety of meaningful experiences. In their 1992 study, DeMaso and colleagues (1) found that many residents who entered a child psychiatry residency from either general psychiatry or pediatrics did so to learn more about normal child development. After completing 3 years of pediatric training I wished to learn more about the emotional life of a child, especially an ill child. I participated in a 1-year clinical fellowship in child psychiatry specially designed for pediatricians. I provided pediatric care to the patients in the psychiatry day hospital program, attended lectures, received supervision, and performed clinical psychiatric duties side-by-side with child psychiatry residents. I learned a new, meaningful way of understanding a child’s experience of being in the world! Eventually, I would complete formal training in child and general psychiatry. In order to do so, I, like others who choose a similar pathway, would have to contend with three important considerations: identity, time, and economics.
The majority of graduates of triple board programs go on to careers in child and adolescent psychiatry (2). It may be that the same is true for graduates of three separate residencies. In our culture pediatricians are a much loved and appreciated group. On the other hand, psychiatry is often misunderstood, misrepresented in movies and other media, and maligned by certain groups like Scientology. Even within the medical profession, psychiatry has struggled to prove its legitimacy. When a pediatrician is identified by the public as a child psychiatrist, it can mean a transition from a position of trust and admiration to one less appreciated.
Personally, I struggled with the idea of becoming a psychiatrist. I feared that I would give back less to society as a child psychiatrist than I would as a pediatrician. While working on a remote Indian reservation I came to understand the importance of psychiatry. After my pediatric training and the fellowship mentioned above I entered the Indian Health Service. There I witnessed first-hand the impact of emotional problems on the physical well being of patients. In many instances, medical interventions could not be effective if psychological issues were not addressed. Mental health resources were scarce and with an overloaded schedule I had little time to use my new psychiatric skills to help my patients. I realized that one cannot be all things to all people, and one’s role must be understood. In performing certain pediatric procedures it is important to be sensitive to a child’s physical and emotional comfort. It is also best to focus on what is needed at the moment rather than to focus on the patient’s emotions. In addition, it may be especially difficult for a physician to be psychotherapeutic with a young patient if that physician must simultaneously perform aggressive procedures necessary for the child’s life or well being. The concept of complimentary roles for the best outcome of a child began to crystallize. I came to value the role of psychiatry as a medical specialty. However, 10 years would pass before I would enter a psychiatric residency.
While time and economics cannot be fully equated, they do go hand-in-hand. To complete three residencies is costly in terms of time and money. Many physicians are deeply in debt by the time they are ready to practice medicine. Neither pediatrics nor child psychiatry are considered high-income specialties. Yet, because child psychiatry tends to bring in more income than pediatrics or general psychiatry, it could eventually be economically advantageous for a pediatrician to complete training in the psychiatry residencies.
Perhaps more difficult than a cut in salary can be the loss of autonomy in one’s practice, to become once again a lowly trainee with long hours under supervision. To be board-certified in child psychiatry a doctor must first receive certification in general psychiatry. The thought of spending 2 years in a general psychiatric residency was the greatest obstacle in my quest to be a child psychiatrist. It was difficult to justify participating in a general psychiatry residency, treating adult patients and suspending work with children, when the ultimate plan was to be better trained to care for children. To make my transition more palatable I entered my child psychiatry residency first. Pediatricians have been shown to perform well in child psychiatry residency programs (1) and my transition went smoothly. Uncomfortable but committed, I finally entered general psychiatry training.
To my surprise, the general psychiatry residency was intellectually and professionally gratifying. I now hold the strong opinion that training in general psychiatry is essential for a child psychiatrist. Child psychiatrists must work with parents. A general residency prepares them to better understand parents, especially those with identifiable psychiatric illness. Approaching parents with sensitivity and understanding is crucial to an alliance, which allows for the treatment of the child. Of even greater importance, during general psychiatry training I was exposed to adults who demonstrated a full spectrum of symptoms that easily identified their psychiatric disorder. As a result, when I later worked with children and adolescents whose symptoms were less clear I had a better sense of which disorders they might be experiencing. A general psychiatry residency provides a breadth and depth of training necessary for the child psychiatrist.
Timing can be even more important than the time itself. Working out a plan that fits emotional and financial circumstances is highly personal. DeMaso and colleagues (1) noted that pediatricians entering a child psychiatry residency had spent a mean of 4.7 years in pediatrics; however, the range is broad. Training may mean moving a family to a new location or separating from a significant other. Flexibility and commitment are required from all involved. I started my child psychiatry residency at a time when the younger of our two children started kindergarten. Knowing there would be financial constraints, our new home became an adventure in itself. We rented a two-hundred year old farm house, acquired pet lambs and hens, camped, played in the snow, and were active in our community. It remains a memorable time for us all. Starting the child psychiatry residency first was beneficial for my family. I could take beeper call and go into the hospital at night as needed, allowing me to see my young children even on the nights when I was on-call. When I needed to stay at the hospital overnight, as part of my general residency, my children were 2 years older and better able to tolerate my absence.
Certification and Recertification
The certification process can be at best an ordeal and at worst a trauma. The time, travel, and expense obviously require strong commitment. The strain on an individual and family can be significant. At the time of my board exams, written and oral examinations were required. Although I had completed training in child psychiatry, I could not take my child boards until after completing training and passing the boards in general psychiatry. Once in practice, in addition to the certification process, there is the time and expense of joining national and regional organizations for each specialty and other organizations of interest. Finally, when you think you are home free it is time for recertification! For many physicians it is necessary to be selective and to prioritize which specialty exams will be most important in the future. While the process of attaining certification in three specialties can be demanding, those with an inner determination will find their own path and, in so doing, will find a new realization of who they are.
Child psychiatrists see themselves as reflective in nature, while pediatricians describe themselves as advocates for children with a more practical bend (3). Because of predisposition or simply because of my training I view myself as a hybrid. I resonate best with those who have a similar triple board training experience yet fully understand and appreciate colleagues from any of the three specialties. Currently, the shortage of child psychiatrists is strongly felt. More than ever child psychiatrists, pediatricians, and general psychiatrists must work closely together to meet the mental health needs of children. A newly developed program which allows pediatricians the opportunity to complete general and child psychiatry residencies in 3 years will not only offer a timely solution for more child psychiatrists but will generate professionals who can help develop bridges between specialties in a time of great need (4).
At the time of submission, the author disclosed no competing interests.