Abraham Bartell, MD

Brown Graduate, 1998

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!