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Triple Board Program for Combined Pediatrics, Psychiatry, and Child & Adolescent Psychiatry Residency Training

Curriculum

The five year Triple Board Program ( TBP ) in pediatrics, psychiatry, and child and adolescent psychiatry enrolls three trainees at the PGY-1 level each year.

The curriculum consists of 24 months of training in pediatrics, 18 months of training in general psychiatry, and 18 months of training in child and adolescent psychiatry. Our residents actively contribute to the evolution of the curriculum, making recommendation to ensure that the program provides a cohesive, planned educational experience rather than a series of rotations among different specialties. Throughout the five years, the curriculum includes clinical and didactic opportunities to integrate the experiences from the three specialties and re sidents are supported with supplementary didactics to support their transition across the specialties. Residents are given increasing responsibility for patient care and teaching as they advance through the years, and the chiefs can choose to serve as junior attendings in the pediatric clinics, pediatric inpatient units, and child psychiatric inpatient units, teaching junior residents and medical students. Because of the history of Brown as a well-established triple board program, residents enjoy the respect of their colleagues and faculty. Additionally, current residents benefit from the mentorship of triple boarded faculty.

The program's didactic curriculum focuses on the basic and clinical sciences of pediatrics, psychiatry, and child psychiatry. Each specialty provides a core didactic program, including morning report and noon conferences in pediatrics, seminars, group and individual supervision in psychiatry and child psychiatry. Additionally, first and second year residents have a triple board-specific curriculum focused on interviewing skills, primary care psychiatry, and behavioral interventions as part of the Psychosocial Clinic.

The program emphasizes the importance of comprehensive pediatric residency training in the first one and a half years. PGY-1 as well as PGY-2 (in the first seven months of the second year) triple board residents participate fully in the clinical rotations and teaching experiences of the pediatric house staff. Triple board residents' schedules differ from the categorical pediatric months in two ways- a behavioral pediatrics month/introduction to child psychiatry month at a day program for children with medical and psychiatric illnesses and an introduction to adult psychiatry month. These modifications of the categorical pediatric curriculum allow the integration of child psychiatry early on while maintaining the focus on pediatric skills and allowing full integration with the pediatric resident cohort. The third year is primarily focused on adult psychiatry, providing exposure to inpatient and outpatient experiences. In the fourth year, the resident formally begins child psychiatry and also spends a significant portion of time in pediatrics. The fifth year residents are primarily assigned to child psychiatry with an emphasis on the integration of their pediatric and adult psychiatry skills. During all five years, residents care for their own panel of patients in a busy hospital-based general pediatric clinic ½ day per week.

PGY-1: 12 months Pediatrics

PGY-2: 7 months Pediatrics, 5 months General Psychiatry

PGY-3: 12 months General Psychiatry

PGY-4: 7 months Child and Adolescent Psychiatry, 5 months Pediatrics

PGY-5: 12 months Child and Adolescent Psychiatry

PGY-1 Curriculum
12 Months of Pediatrics

The PGY-1 year is the time for developing a solid foundation in pediatrics. Residents treat patients with a wide spectrum of disease, symptom severity, and ages from newborns to adolescents. Most rotations are within the state's only children's hospital, Hasbro Children's Hospital, which serves as a referral center for Rhode Island, northern Connecticut, and southern Massachusetts, as well as a community hospital for Providence residents. Adjacent to Hasbro, is Women and Infant's Hospital, the region's largest delivery center. Residents spend 4 months on the general inpatient units, 2 months in an active level 3 neonatal intensive care unit and one month in the pediatric intensive care unit. In addition, they treat patients in the emergency department for 2 months, adolescent clinic for one month and the normal nursery for a month. Residents in the PGY-1 year have 3 call-free months.

The didactic portion of the pediatric training occurs on teaching rounds as well as in case-based morning reports with residents and faculty and through a daily noon conference series on clinically important topics. Hasbro Children's Hospital has a growing hospitalist department, who provide excellent clinical supervision and didactics on the inpatient rotations. Each team on the wards also has a dedicated teaching attending with expertise in community pediatrics or a pediatric subspecialty.

In the first and second year clinic, residents have a unique opportunity to experience the interface between pediatrics and child psychiatry. One clinic per month is designated as a psychosocial clinic in which 2 general pediatric patients with especially complex behavioral or psychosocial issues are seen by the residents with a faculty psychiatrist or psychologist. The interview is done through a one-way mirror with a child psychologist and triple boarded faculty member to allow all of the residents to observe and discuss the case.

PGY-1 residents are introduced to child psychiatry through a month in the pediatric partial hospitalization where they begin to learn concepts of individual, group and family therapy. In addition, each resident has a Triple Board "tutor-advisor" beginning in the first year, to facilitate professional development and identify additional opportunities of interest, such as advocacy or research activities.

PGY–2 Curriculum
Pediatrics and Adult Psychiatry
7 months of Pediatrics
5 months of Adult Psychiatry

The second year begins in pediatrics to continue to build a solid pediatric foundation. Residents act as senior residents on the wards for 2 months, and in the NICU for one month. They treat patients in the ER for a month, and have exposure to pediatric specialties including neurology, surgery as well as an elective. During the first portion of the year, all second year residents also rotate through the adult psychiatry emergency and crisis service, a closely supervised rotation intentionally developed to provide an introduction to general psychiatry interviews and treatment modalities before residents transition to the adult inpatient units. Residents continue to attend pediatric morning report and the daily noon conference series.

In the eighth month of the second year, PGY-2, TBP residents transition to adult psychiatry. They rotate on adult psychiatry inpatient units at Butler Hospital, Rhode Island Hospital, and/or the Veteran's Administration for three months. The residents also complete a one-month rotation of adult neurology. In the latter five months of PGY-2, the resident may initiate one to two adult psychotherapy cases with supervision. They begin adult psychiatry didactics with the general psychiatry residents in the second part of the year, and also have weekly meetings with the Training Director of the General Psychiatry program to ensure a smooth transition into this portion of their training.

As in the first year, residents continue their pediatric continuity clinic throughout the second year and continue to participate in the monthly “psychosocial clinic” as described above

PGY-3 Curriculum
12 months of Adult Psychiatry

* = Rhode Island Hospital
**= Veterans’ Administration Medical Center

The emphasis of PGY-3 is primarily on adult psychiatry. During this year, the resident participates in eight months of adult outpatient psychiatry, two months of adult psychiatry consultation-liaison, one month of adult emergency psychiatry, and one month of inpatient adult psychiatry. During the adult psychiatry inpatient rotation in PGY-3, residents are expected to work in a supervisory role and efforts are made for them to be assigned at sites with PGY-2 TBP residents whom they may supervise.

The components of the adult psychiatry experience may vary in order and duration between the last five months of the PG-2 year and the 12 months of the PG-3 year, depending on scheduling issues. The emphasis of these assignments is on the development of continuity of care a nd consolidation of skills in patient evaluation and individual psychotherapy.

While on adult psychiatry rotations, PGY-2 and PGY-3 Triple Board residents participate in the PGY-2 and PGY-3 general psychiatry seminars on the Basic Sciences of Psychiatry, Social and Cultural Psychiatry, Community Psychiatry, and Individual, Group, Family, and Behavioral Psychotherapy. They also receive weekly supervision for their inpatients and outpatients, and attend monthly psychiatry grand rounds. Their experience is similar to that of the adult psychiatry residents, except that continuity and integration with pediatrics and child psychiatry are emphasized.

Pediatric Continuity Clinic (one-half day per week) is continued. Additionally, supervision with a triple board "tutor-advisor" is continued to allow ongoing professional development.

PGY-IV Curriculum
Child Psychiatry/Pediatrics
7 months of Child Psychiatry (Bradley Hospital)
5 months of Pediatrics (Hasbro Children’s Hospital)

The fourth year provides training in child psychiatry and integration of pediatrics, with a unifying focus of understanding our patients in the context of the family. Training in psychosocial growth and developmental psychopathology helps to solidify the resident's identity as a child and family-oriented physician.

The resident starts the year in Child Psychiatry at Bradley Hospital . During the first seven months, the resident rotates through three months of adolescent psychiatry inpatient, two months of child psychiatry inpatient, one month of the Developmental Disabilities Program, and one month of the Crisis Service.

During the PGY-4 year, TBP residents attend a minimum of four hours per week of seminars in child and adolescent psychiatry, including Developmental Psychopathology and Psychotherapy, Child Development, Family, Group and Behavior Therapy, Pediatric Neuropsychiatry and Neuropsychology, Developmental Research Seminar and the Infancy Seminar. They have weekly supervision for their clinical rotations and their long-term therapy cases, and attend monthly department and weekly child psychiatry grand rounds.

During child and adolescent, and adult psychiatry training, residents treat outpatients that are suitable for long-term treatment and cover all of the developmental age periods. Specific training and supervision in family therapy, cognitive behavioral therapy, and interpersonal therapy are provided in the PGY-4 and PGY-5 years.

In the last five months of the PGY-4 year, residents return to pediatric rotations. During this time they have five one-month rotations which include Pediatric Hematology/Oncology, elective, Child Protection Team, emergency department, and Urgent Care. Residents are encouraged to consolidate their pediatric skills. Pediatric continuity clinic and long-term psychotherapy training with adult and child outpatients are maintained throughout the year.

PGY-V Curriculum
12 months of Child Psychiatry

* Electives can include additional experiences in community mental health centers, ambulatory pediatric settings in consultation role, increased exposure to specific child psychiatry populations.

**Additional supervisory pediatric experience in the PGY-V year can be elected.

During the PGY-5 year, the emphasis is on consolidating child and adolescent psychiatry experience, while maintaining adult long-term psychotherapy and pediatric continuity clinic experience. The year is focused on child and adolescent psychiatry outpatient, consultation-liaison (CL), partial hospital, forensic psychiatry and community mental health clinical rotations. During the 4 month CL rotation, the resident is given increasing responsibilities to assume a junior attending role, to encourage leadership, and teaching skills. The one-month rotation in forensic psychiatry allows residents the opportunity to work at the Rhode Island Training School (juvenile detention center) and acquire knowledge about forensic evaluations. Residents may also rotate on the partial hospitalization program at Hasbro- providing care to children and families affected by medical and psychiatric disorders, or at Bradley, serving children under 6-years-old. The emphasis in these assignments is on continuity of care, the development of consultation-liaison skills, the consolidation of evaluation skills, and continued experience in short- and long-term individual, group, and family psychotherapy.

In their elective time, Triple Board residents are encouraged to develop a scholarly project that combines child psychiatry and pediatrics. Many electives are available, including Bradley Day School (which includes a school consultative experience), Early Childhood Clinic ( Bradley Hospital ), Clinics (Anxiety, Infant, and Sleep), and Pediatric Neurology. Residents can hone their cognitive behavioral therapy skills by participating with the Pediatric Anxiety Research Clinic team, providing care through an NIMH-funded research protocol. Other residents have developed research projects in collaboration with faculty mentors, receiving funding from the American Academy of Pediatrics and the American Academy of Child and Adolescent Psychiatry.

Residents continue to have 2-3 hours a week of one-on-one supervision with attendings to discuss outpatient patient and treatment modalities including various forms of psychotherapy and pharmacotherapy. PGY-5 residents may serve as junior attendings in the pediatric clinic to teach and supervise TB or pediatric residents. Additionally, PGY-5's can serve as liaisons to pediatric units or clinics, and are encouraged to serve as attendings on pediatric or child psychiatry inpatient units, in order to further consolidate their knowledge and skills. PGY-5 TBP trainees continue to attend the child and adolescent psychiatry seminars and receive supervision for clinical assignments and long-term therapy training as previously described. Senior residents present cases at a clinical case consultation and participate in a journal club with federally-funded researchers and academic clinicians.