Approximately twenty years ago it became evident that two major problems existed in the field of Child and Adolescent Psychiatry. First was the enormous dearth of all Child and Adolescent Clinicians; there were simply not enough Child and Adolescent Psychiatrists to go around. The second problem concerned the relationship between the Pediatric and Child and Adolescent Psychiatry communities, specifically, there had to be a better way for Pediatricians and Child and Adolescent Psychiatrists to work collaboratively on the many issues that they share.

There were many solutions advanced to address these issues. The "Triple Board" concept was to create an alternative pathway of training to become a Child and Adolescent Psychiatrist that would combine Pediatric, General Psychiatry, and Child and Adolescent Psychiatry, while accomplishing it in less time than the conventional path that would take seven or eight years. The goal of the combined training program was to create a nucleus of academically-based Child and Adolescent Psychiatrists that were trained and socialized as Pediatricians, who could bridge the gap between the worlds of Pediatrics and Child and Adolescent Psychiatry. Additionally it was hoped that this core of "Triple Boarders" would remain in academic Child and Adolescent Psychiatry and serve as a magnet in the academic environment to attract medical students and residents to the specialty field of Child and Adolescent Psychiatry.

In 1986 the Triple Board Program was born. The combined program in Pediatrics, General Psychiatry, and Child and Adolescent Psychiatry, is a five-year program that combines 24 months of Pediatrics, 18 months of General Adult Psychiatry, and 18 months of Child and Adolescent Psychiatry. Upon completion of Triple Board training, graduates are eligible to take the Board Certification exams offered by all three disciplines.

The first Triple Board Programs began in 1986 as part of a ten-year pilot. The pilot program was the first of its kind to prospectively study the efficacy and appropriateness of a new training program. The programs were overseen by the PPJTC, The Pediatric-Psychiatry Joint Training Committee, a specialized group comprised of members from the American Council on Graduate Medical Education, the American Board of Pediatrics, the American Board of Psychiatry and Neurology, and several other organizations. The results of the pilot were so clear and convincing that the programs were fully accredited in year eight of the pilot, two years early. The pilot consisted of six programs, the Albert Einstein College of Medicine, Brown University, the Icahn School of Medicine, Tufts University, the University of Kentucky, and the University of Utah. Each of the original six-programs accepted two trainees per year. Once the Triple Board Programs were fully accredited, five additional programs were started at the Indiana University School of Medicine, the University of Cincinnati, the University of Hawaii, the University of Texas at San Antonio, and the University Health Center of Pittsburgh. There are currently nine active programs accepting new trainees: Brown, Cincinnati, Hawaii, Indiana, Kentucky, Mount Sinai, Pittsburgh, Tufts, and Utah, with a total of nineteen positions offered through the NRMP match each year.

For more information on the program structure and requirements contact the American Board of Pediatrics or the American Board of Psychiatry and Neurology, and for a complete list of programs see the ACGME Green Book or FRIEDA online.

There are well over 150 "Triple Boarders" including graduates and the current trainees. Graduates of the programs have gone on to practice all three specialties, and in some cases, more than one at the same time. A recent review of graduates showed that approximately 50 percent stay in academic positions for at least some part of their early careers. Triple Board graduates predominantly practice Child and Adolescent Psychiatry although in very different settings. The practice settings include acute inpatient units, residential facilities, day treatment programs, forensic psychiatry, outpatient treatment in both the public and private sector, and very often in the medical setting either as Consultation Liaison Psychiatrists or by addressing the mental and behavioral health issues of medically ill patients in the medical setting. A portion of the graduates have completed additional training in areas as diverse as Infant Psychiatry, Public Psychiatry, Personality Disorders, Eating Disorders, Psychoanalytic Training, Neuropsychiatry, Pediatric Emergency Medicine, Pediatric Hematology and Oncology, and Pediatric Intensive Care Medicine. Additionally some graduates have gone on to masters level work, including M.B.A. and M.P.H. degrees, and doctoral work. The strength and beauty of the program are that every graduate is doing something unique and different in her/his integration of the training.

Now that you know what Triple Board is, how do you know if it is for you? Triple Board is not for everyone! It is a demanding program mostly as a function of its compressed nature. Often students ask how it compares to or differs from conventional Child and Adolescent Psychiatry training. Triple Board training is "different" than conventional training and it is difficult to do a head to head comparison.

To figure out if it is for you, you need to consider the goals of Triple Board. It is not necessarily to train you to be "all three" but rather to be a different type of and uniquely trained Child and Adolescent Psychiatrist; what some have begun to call a "Pediatric Psychiatrist." Many fourth year medical students do electives at one of the sites in order to learn more about Triple Board in general and the specific programs in which they are interested.

Triple Boarders have often said that they chose Triple Board because they found what attracted them most to the pediatric population could not be accomplished as a pediatrician, specifically the psychosocial, developmental, behavioral, and cultural aspects of the pediatric population. Some have reported choosing Triple Board because they did not want to lose their sociocultural identity as "real doctors" while practicing Child and Adolescent Psychiatry. More importantly they feel that one cannot disconnect the medical and biological aspects of children from their behavioral and developmental issues and that the best way to avert that disconnect is to be Triple Board trained. There are still others that enjoy "living and working" within the interface between the medical and mental health communities.

Regardless of the reasons and rationales for choosing Triple Board, and regardless of the career paths chosen after graduation, there is a nearly universal consensus that the training was unique and rewarding. Despite the challenges and intensity of Triple Board training, all the graduates felt well trained and prepared for the next phase of their careers. The overwhelming majority had no regrets in their choice and would do it again if they were starting over.

I strongly suggest, as both a Triple Board graduate and program training director, that if you are thinking about a career in Pediatrics and/or Child and Adolescent Psychiatry that you give serious consideration to Triple Board.

John D. O’Brien, MD
Clinical Professor of Psychiatry
Director of Training, Child and Adolescent Fellowship
Director of Training, Triple Board Program
Tel: (212) 241-0487
E-mail: john.o’

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