The five year combined residency integrates Pediatrics, General Psychiatry, and Child and Adolescent Psychiatry to train physicians who synthesize the clinical knowledge and skills of these disciplines. The training provides a foundation for clinical care, education, advocacy, public policy and research with a developmentally informed biopsychosocial approach to health, illness, and prevention. This unique program transcends the boundary between pediatrics and psychiatry in order to optimize the care of children, adults, and families in community and academic settings.

Residents in triple board programs train for 2 years in pediatrics, 1 ½ years in adult psychiatry training and 1 ½ years in child and adolescent psychiatry. At the end of the training, residents are board eligible in all three disciplines.

Historically, triple board programs were established more than 20 years ago to develop a cadre of child psychiatrists trained in pediatrics to help bridge the gap between the two disciplines. Since then, the scope of triple board training has widened and a unique “triple board identity” has developed, transcending the boundaries between pediatrics and child psychiatry. Graduates of triple board residencies have pursued remarkably varied careers, all with a strong foundation of integrated pediatric and child psychiatry training.

Some triple boarders choose to pursue careers in traditionally psychiatric settings where their pediatric skills and knowledge provide additional insight into normal development, understanding of children’s medical illnesses and treatments and medication issues. Graduates treat children on consultation-liaison teams, inpatient child psychiatry units, outpatient private practice or mental health centers, forensic psychiatry, infant psychiatry and caring for patients with developmental disabilities.

Others triple boarders choose to practice in predominantly pediatric settings where their training provides a depth of understanding of children’s and family’s responses to psychosocial and medical stressors, developmental disabilities and the impact of psychiatric illnesses on individuals and their families. Triple board graduates have pursued subspecialty training in child abuse, hematology-oncology, pediatric emergency medicine, adolescent medicine, and pediatric critical care. Some also treat general pediatric patients in private practice.

In all settings, triple boarders have developed unique and exciting career paths caring for children and their families.

Want to learn more about the individual programs? Please check the programs’ Web sites and contact the programs!

Objectives

The objectives of a combined residency in pediatrics-psychiatry-child and adolescent psychiatry include the training of general physicians for practice/academic careers that address the spectrumof mental and emotional illnesses in the newborn, children, adolescents, and adults. Graduates of a combined residency may function in practice and academic environments or enter into further subspecialty training. This clinical training can also prepare graduates to undertake research training in areas shared by psychiatry and pediatrics.

The strengths of the residencies in psychiatry, child and adolescent psychiatry, and pediatrics should complement each other to provide the optimal educational experience.

Combined training residencies include residency training programs in psychiatry, child and adolescent psychiatry, and pediatrics that are accredited respectively by the Residency Review Committee (RRC) for Psychiatry and by the Residency Review Committee (RRC) for Pediatrics, both of which function under the auspices of the Accreditation Council for Graduate Medical Education. The training in each combined residency must be approved by the American Board of Pediatrics and the American Board of Psychiatry and Neurology. The Boards will not accept training in a newly established combined residency if the accreditation status of the residencies in any of the three disciplines is provisional or probationary. If any of the residency training programs is accredited on a probationary basis, residents should not be appointed to a combined residency.

General Requirements

A combined residency in psychiatry, child and adolescent psychiatry, and pediatrics must include at least 5 years of coherent training integral to all three residencies that meet the Program Requirements for accreditation by the RRC Psychiatry and RRC Pediatrics.

The participating residencies must be in the same academic health center (effective July 1, 2000). Documentation of hospital and faculty commitment to the combined residency must be available in signed agreements. Such agreements must include institutional goals for the combined residency. Affiliated institutions must be located close enough to facilitate cohesion among the residencies' house staff, attendance at weekly continuity clinics and integrated conferences, and joint faculty interaction in regard to curriculum, evaluation, administration, and related matters.

The training of residents while on pediatric rotations is the responsibility of the pediatric faculty, while on psychiatry rotations the responsibility of the psychiatry faculty, and while on child and adolescent psychiatry the responsibility of the child and adolescent psychiatry faculty. Vacations, leave, and meeting time will be shared proportionally by all three training programs (40% pediatrics, 30% general psychiatry, and 30% child and adolescent psychiatry). Maternity/ paternity leave policy should be prorated for each specialty and consistent with each Board's individual leave policy.

Any absence of more than 2 months of the 2 years of the pediatric training should be made up by the same amount and type of training missed.

Any absence in excess of the institutionally approved vacation, meeting, or leave time during the 18 months of general psychiatry training and the 18 months of child and adolescent psychiatry training should be made up by the same amount and type of training missed.

The Resident

Residents should enter a combined residency at the R-1 level. A resident may enter a combined residency at the R-2 level only if the first residency year was served in a categorical residency in pediatrics. Residents may not enter a combined residency from a pediatric residency or transfer between combined residencies without prospective approval by both Boards. The number of residents allowed per year will be based on the combined residencies' educational capacity, but there should be at least two trainees per year.

The Combined Residency Director(s)

The combined residency must be coordinated by a designated full-time director or by codirectors who devote sufficient time and effort to the educational program. An overall residency director may be appointed from any of the three specialties. The directors must embrace similar values and goals for their residency. If a single residency director is appointed, an associate director from the other specialties must be named to ensure both integration of the residency and supervision in each discipline. An exception to this requirement would be a single director who is certified in all three specialties and has an academic appointment in each department.

Core Curricular Requirements

A clearly described written curriculum must be made available for residents, faculty, both Residency Review Committees, and both Boards prior to the initiation of the combined residency. There must be 24 months of training in pediatrics, 18 months of training in general psychiatry, and 18 months of training in child and adolescent psychiatry. The curriculum must assure a cohesive, planned educational experience and not simply comprise a series of rotations among the specialties. Residents must be accorded graded responsibility for patient care and teaching. Annual review of the residency curriculum must be performed by the chairs of both departments with consultation with residents and faculty from both departments.

Care must be exercised to avoid unnecessary duplication of educational experiences in order to provide as many opportunities as possible.

Each supervising director must document at least monthly meetings that include all combined residents for educational activities such as jointly sponsored journal clubs, feedback on performance, counseling, visiting professors, clinic conferences, occasional combined grand rounds, medical ethics conferences, or research projects.

Residents shall be encouraged to follow their pediatric outpatients when hospitalization is required.

Requirements for Pediatrics

The Scope of Training

The development of the resident's skills in pediatrics will be fostered by rotations on general pediatric services, both inpatient and outpatient, with exposure to a wide spectrum of disease. The resident must be exposed to pathologic conditions ranging from mild to severe illness, including life- threatening conditions that require critical care. Fifty percent of clinical training must be in ambulatory settings.

The pediatric patient population served must encompass adequate numbers and extend from the newborn (including premature infants) through childhood and adolescence.

Residents must have graduated patient care responsibility throughout their experience. It is essential that the resident, while on the pediatric service, have senior supervisory experience for at least 4 months.

Specific Experiences

A. Subspecialty Experience

There must be time to allow the residents to broaden their pediatric experience in the pediatric subspecialties. When on the subspecialty services, the resident must have the opportunity to behave as a consultant, under appropriate supervision. The total duration of time committed to these rotations should be at least 4 months. The individual rotations should be for 1 month; however, two subspecialty rotations may be combined and taken together over a 2-month period providing the two rotations can be integrated appropriately.

Subspecialty rotations may be either inpatient, outpatient, or a combination thereof. The specific rotations that the resident takes should be those that will add to the resident's educational spectrum, but they should also conform in content with the Program Requirements for Residency Education in Pediatrics. Residents should be supervised by qualified pediatric subspecialists and have access to appropriate clinical laboratories.

There must be a structured educational experience to train residents in the medical and psychosocial problems of the adolescent. This rotation must be for at least 1 month. During this time, experience in adolescent gynecology should be available.

B. Ambulatory Service

In keeping with the commitment of pediatrics to primary and comprehensive care, the 5-year combined residency must provide for 50% of the pediatric experience in ambulatory settings. This may include all assignments in continuity clinic, acute illness and emergency department, and community-based experiences, as well as the ambulatory portion of the normal newborn, subspecialty, behavior/development, and adolescent experiences.

2. Acute Illness Clinic and Emergency Department - These rotations must be educational experiences adequately supervised by pediatric faculty. The patient load should be kept reasonable with due consideration being given to the level of training of the resident, the ratio of new patients to return visits, and the complexity of the problems. The duration of such assignments must total at least 3 months, with 1 month in a block rotation in an emergency department that serves as the receiving point for EMS transport and ambulance traffic and is the access point for seriously injured and acutely ill pediatric patients in the service area. Training in minor surgery and orthopedics should be included in this rotation. Assignment to an acute care center or walk-in clinic to which patients are triaged from the emergency department will not fulfill this requirement.

3. Continuity Clinic - To ensure an understanding of the longitudinal aspects of disease, as well as growth and development, the resident must be responsible for continuity of care for a group of pediatric patients throughout all of the 5 years. Residents must have weekly or every other week assignments to such clinics, during which they are relieved of other duties. Their patients should include those they cared for in the hospital and consist of children and adolescents of various ages, both well and with chronic disease and/or developmental problems. The resident should provide comprehensive care and should function as part of a healthcare team. Subspecialty consultants should be available to the residents as they care for these patients. The residents should arrange for the care of their patients when they themselves are not available. Consideration should be given to the establishment of a combined continuity clinic for patients with pediatric and psychiatric problems, but trainees must not treat only patients with psychiatric disorders.

C. Inpatient Experience General pediatric inpatient care should be for a period of 5 months. The resident's responsibility should be that of the primary caregiver. Supervisory responsibility for inpatients must be provided to each resident for at least 2 months during the latter part of training. Training.

D. Intensive Care Experience The required experience in NICU and PICU must be limited to a total of 4 months, of which 3 months must be NICU and one month PICU experience.

E. Normal Newborn Nursery At least 1 month must be spent in the care of the normal newborn infant.

F. Study of the basic sciences should be part of the clinical education of the resident. This is most effectively provided in an integrated manner at the patient's bedside and in conferences.

Requirements for General Psychiatry

A. The curriculum must include adequate and systematic instruction in basic biological (eg, neuroscience) and clinical sciences relevant to psychiatry, in psychodynamic theory, and in appropriate material from the social and behavioral sciences (eg, psychology, sociology, anthropology).

B. Each resident must have major responsibility for the diagnosis and treatment of a reasonable number and adequate variety of adult patients suffering from all the major categories of mental illness. Adequate experience must also be assured in the diagnosis and management of the general medical and neurological disorders encountered in psychiatric practice.

C. Significant responsibility must be obtained for the diagnosis and treatment of an appropriate number and variety of adult psychiatric inpatients for a period of not less than 4 months but no more than 9 months (or its full-time equivalent).

D.No less than 6 months but no more than 9 months (or its full-time equivalent) is required in an organized and well-supervised outpatient program that includes experience with a wide variety of adult disorders, patients, and treatment modalities and with experience in both brief and longterm care of patients, utilizing both psychological and biological approaches to outpatient treatment. Long-term treatment experiences must include a sufficient number of patients, seen at least weekly for 1 year or more, under supervision

E. The following requirements can be completed in psychiatry, in child and adolescent psychiatry, or preferably a combination of both.

1. Supervised clinical experience in the diagnosis and treatment of neurological patients (preferably this would be in pediatric neurology).

2. Supervised psychiatric consultation/liaison responsibility, involving patients on medical and surgical services.

3. Supervised responsibility on a 24-hour psychiatry emergency service as an integral part of the residency, and experience and learning in crisis intervention techniques, including the evaluation and management of suicidal patients.

4. Supervised responsibility in community mental health activities.

5. Supervised active collaboration with psychologists, psychiatric nurses, social workers, and other professional and paraprofessional mental health personnel in the treatment of patients.

6. Supervised experience with the more common psychological test procedures in a sufficient number of cases to give the resident an understanding of the clinical usefulness of these procedures and of the correlation of psychological testing findings with clinical data.

Requirements for Child and Adolescent Psychiatry

A. There must be systematic teaching of the biological, familial, psychological, and cultural substrata of normal development and psychopathology in children from prenatal life through the age of middle adolescence.

B. All clinical experiences must be well supervised and include the treatment of preschool, primary school-age, and adolescent patients of varied economic and sociocultural backgrounds with the total spectrum of mild to severe psychopathology.

Treatments must include psychopharmacologic, individual psychodynamic, behavioral, and family therapeutic modalities.

D. There must be teaching and supervised experience in pediatric neurology, if not obtained previously in pediatrics.

E. Outpatient therapy must include some child and adolescent patients in psychodynamic psychotherapy for at least 1 year.

F. There must be experience for more than 2 months but no more than 6 months (or its full- time equivalent) in either an inpatient ward, a day hospital, or a residential treatment center that includes 24-hour responsibility for patients. There may be a combination of at least 2 months each in two or three of these settings.

G. Consultation experience must be in at least two areas, including to children and/or adolescents in pediatric, educational, and/or legal settings.

H. Although the majority of teaching must be from child and adolescent psychiatrists, there must also be clinical experience with professionals from other medical specialties, nursing, psychology, and social work.

Evaluation

Periodic evaluation with feedback of the educational progress of the residents is required as outlined in the program requirements for the categorical residencies. Included in this evaluation must be residents' knowledge, skills, attitudes, and interpersonal relationships. These evaluations must be written and regularly discussed with the residents and must be kept on file and available for review. All residents should also take the ABP In-training Examination (ITE) and the ABPN Psychiatry Resident In-training Examination (PRITE) each year. The teaching faculty must be evaluated on a regular basis, and the residents must participate in these evaluations. The supervising directors from each specialty must document meetings at least semiannually to monitor the success of the combined residency and the progress of each resident. Annual review of the residency curriculum must be performed by the chairs of the department of pediatrics and the department of psychiatry with consultation with residents and faculty from all three areas.

To meet eligibility requirements for triple certification, the resident must satisfactorily complete 60 months of combined training and his/her clinical competence must be verified by the directors of each program. Lacking verification of acceptable clinical competence in the combined residency or if the resident leaves combined training, the resident must satisfactorily complete the standard length of residency training and all other requirements of each or either certifying board. A candidate may apply for the certifying examination in general pediatrics in his/her fourth year of combined residency and take the examination in the fall of their fifth year if they have successfully completed all pediatric training requirements except for continuity clinic by that time.