HISTORY OF THE TRIPLE BOARD PROGRAM

By Dr. Abe Bartell

Approximately twenty years ago it became evident that two major problems existed in the field of Child & Adolescent Psychiatry. First, there was an enormous shortage of Child & Adolescent Psychiatrists. Secondly, there was a perceived disconnect and strain between Child & Adolescent Psychiatry and Pediatrics. Most notably, fewer Pediatricians were seeking Child & Adolescent Psychiatry training, and it appeared that fewer Pediatricians were referring to Child & Adolescent Psychiatrists. The former was significant because the origins of Child & Adolescent Psychiatry lie in the post-World War II Pediatric community. In an Editor’s Note (1989) describing the inception of the TBP, Dr. John Schowalter described that the Committee on Certification in Child Psychiatry (CCCP) was interested in capturing the students interested in both the medical and psychological disorders of childhood.

There were many solutions considered to address these issues and the Combined Residency in Pediatrics-General Psychiatry-Child and Adolescent Psychiatry ("“Triple Board”) was one of them. The “Triple Board” concept was to create an alternative pathway of training to become a Child & Adolescent Psychiatrist that would combine Pediatric, General Psychiatry and Child & Adolescent Psychiatry training and would allow a path less than that required in the conventional training sequence of seven or eight years. One of the goals of the combined training program was to create a nucleus of academically based Child & Adolescent Psychiatrists that were trained and socialized as pediatricians who could bridge a gap between the Pediatric and the Child & Adolescent Psychiatry communities. Additionally, it was hoped that this core of “Triple Boarders” could serve as a magnet in the academic environment to attract medical students to the specialty field of Child & Adolescent Psychiatry.

The goal was to develop a combined program in Pediatrics, General Psychiatry, and Child & Adolescent Psychiatry in five years that combined 24 months of Pediatrics, 18 months of General Psychiatry, and 18 months of Child & Adolescent Psychiatry training. Upon completion of Triple Board Training graduates would be eligible to sit for the Board Certification examinations offered by all three disciplines.

From 32 initial applications from institutions, six were chosen to be sites of a TBP Program (Einstein, Brown, Mount Sinai, Tufts, Kentucky, Utah). On July 1, 1986, the first group of residents started in the new Triple Board Program. (The reader is directed to “An Experiment in Graduate Medical Education, Schowalter et al., 2002 for a review of the development of the TBP.)

The initial interest in, commitment to, and oversight of the TBP was impressive. The Pediatrics-Psychiatry Joint Training Committee (PPJTC) was comprised of representatives from the Committee on Certification in Child and Adolescent Psychiatry (Dr. Schowalter), the American Board of Pediatrics (ABP) (Drs. Benton and Stockman), the American Board of Psychiatry and Neurology (ABPN) (Drs. Scheiber and Miller), the American Academy of Pediatrics (AAP) (Dr. Daeschner), American Academy of Child and Adolescent Psychiatry (AACAP) (Dr. Enzer), and the American Psychiatric Association (APA) (Dr. Scully). Additionally, there was a NIMH representative (Dr. Haas) and a professional educator (Dr. Friedman). Funding was provided from the NIMH, Center for Mental Health Services, ABP, and ABPN for the PPJTC to prospectively administer and assess the program.

The initial six programs had vigorous oversight by all the above components. There were annual site visits with all the residents, and the Training Directors and summary site reports were generated. (Residents took the Myers-Briggs Personality Test as part of their participation.) Each program was regularly site visited, and there were annual resident retreats and meetings. Medical students who interviewed at TB Programs, but did not choose that residency, were sought for feedback as to why they had decided not to choose the combined option. This close "monitoring" and "ownership" was beneficial, and the programs thrived. (See Schowalter et al., 2002 for a review of the prospective evaluative process.) Ultimately, the experiment was considered a success, and in 1995 (when the fifth and last cohort of pilot project residents completed training) the combined program was voted in as a permanent residency. The pilot program was the first of its kind to prospectively study the efficacy and appropriateness of a new training program. The results of the 10-year pilot project were so clear and convincing that the programs were fully accredited in year eight of the pilot, two years early!

The Future of Triple Board Programs

By Dr. Doug Gray

Triple board programs were initially designed as a way to draw medical students into the field of child and adolescent psychiatry, especially those who were struggling between the choices of pediatrics, or child psychiatry. Pilot programs began in 1986, and currently there are ten triple board programs.

At first glance, a medical student looking at the triple board might assume this would be a way to keep career options open. They could graduate, and practice either pediatrics, or psychiatry, or spend some time in each area. While this might be the case for some applicants, this goal is too limiting and misses the full potential of the training. Triple board residents can have remarkable careers in areas that require use of all of the skills gained in the program. For example, graduates are perfectly trained to work in large university or children’s hospitals doing consultation-liaison work. Their training allows them to communicate well with both the pediatric and psychiatric staff, and they are well suited to work between the two groups. There are also diagnostic areas, such as eating disorders, that require several skill sets. Some triple board graduates work with anorexic patients, first on the pediatric unit, working with nursing staff and managing the patient’s acute medical needs, then later working with the psychiatric team when the patient is transferred to an inpatient psychiatric unit, and then to the outpatient team. One doctor oversees the care throughout the continuum, vastly improving patient care. Triple board graduates run clinics taking care of patients with chronic medical illness, where psychosocial problems are effecting compliance and causing acute hospitalizations. Some triple board graduates share clinics with neurologists, seeing kids with central nervous system problems, such as head injuries, and they manage subsequent psychiatric problems. Current triple board residents are exploring new avenues, such as development of combination pediatrics and psychiatry clinics for children in foster care, where their emotional and medical needs can be met in one clinic. Combining current funding sources for these children under one roof, can lead to an integrative model. The triple board graduate is truly the “ultimate developmental specialist,” with training on both mental and physical aspects of child development.

Unfortunately, many medical students have never heard of the triple board, and it will be important to educate students regarding the opportunity to integrate physical and mental health care for children, especially when the medical student is drawn to both areas of study. Dr. Thomas Anders, MD, the incoming president of the American Academy of Child and Adolescent Psychiatry (AACAP) has made a commitment to support the Triple Board Programs, and to increase knowledge and awareness about these programs. Dr. Anders recognizes that the national shortage of child and adolescent psychiatrists must be addressed in a number of ways, including the development of new “Portals” into the field, and the growth and expansion of the Triple Board Programs. To address this issue, in 2005, he created a position for a Triple Board Training Director as Co-Chair of the Training and Education Workgroup, for AACAP. The first effort in the education process will be the development of a National Triple Board website. From there, potential applicants will be able to access information regarding Triple Board training, as well as websites from each individual program. Once the national website is up, efforts will be made to provide links to the Triple Board website, on other national websites visited by medical students, residents, and attendings who are invested in either pediatrics or child psychiatry. In addition, efforts will be made to contact training directors for both pediatrics and psychiatry at their national meetings, and to educate them about Triple Board Training.

The triple board model has been successful and we expect to see new programs in the future. Several national leaders in the field of child psychiatry are looking at how expansion should proceed. This may involve the recruitment of universities who might be well suited to start triple board programs, the availability of national consultants to help them with planning, and the support of new programs by both pediatrics and psychiatry. While there are many excellent programs in the Northeast, expansion is needed to areas such as California, where there are many metropolitan universities which could support a triple board program.

A friend who is an experienced family doctor once told me that half of the patients he sees in his office are coming for emotional support, and have vague symptoms. Of the half that has physical findings (i.e. wheezing, high blood pressure), many of those are not compliant with their treatment because of emotional issues. This leaves 25% of the patients who caught strep throat, broke their hand, etc. Unfortunately for primary care doctors, they get very limited training in psychiatry. Referring patients to a separate clinic for mental health needs is very difficult, and often the patients don’t show up. For these reasons we need an integrative model for physical and mental health, and for pediatric patients, triple board graduates will lead the way.