To the Editor:
The 5-year combined training program in pediatrics, general psychiatry, and child and adolescent psychiatry (Triple Board Program), originally conceived as an experiment in medical training, has established itself as a sustainable pathway in recent decades. While early evaluations focused on the primary objective of addressing the shortage of child psychiatrists, more recent reflections have emphasized the novel perspective and skillset fostered by training in the integrated program . The importance of these considerations has only been amplified in the setting of the ongoing COVID-19 global pandemic. At a time when the healthcare workforce and stock of personal protective equipment are being stretched, institutions are working overtime to consolidate and conserve resources . With one foot planted firmly in the realm of pediatrics, and the other in psychiatry, Triple Board physicians stand in a unique position to contribute in a variety of hybrid roles to help ensure that children continue to receive the care they need while also limiting exposure risks and supporting infection control.
In anticipation of the expected surge in cases related to COVID-19, and the prospect that frontline pediatric providers may be deployed to cover adult medicine units, a pilot project was initiated at Hasbro Children’s Hospital in Providence, Rhode Island, in March of 2020. With the support of both pediatrics and child psychiatry leadership, a position was created on a trial basis for a senior Triple Board resident. The envisioned role was conceptualized as being hybrid in nature―serving as a pediatrics senior resident for patients admitted to a medical bed awaiting availability at a psychiatric facility, as well as an extended member of the inpatient child and adolescent consult-liaison psychiatry team. Rationale supporting the initiative included the reality that by the fifth year of most Triple Board curriculums, trainees have completed the majority of their pediatrics requirements, are often board-certified pediatricians, and also serve as child psychiatry fellows. The hope was to streamline communication, expedite disposition planning, and offer a familiar point of contact on-site as much of the psychiatry department’s consultation activities transitioned to telemedicine.
A notable circumstance, for which the hybrid role has been particularly beneficial, has been in the management of primarily psychiatric patients admitted to a medical bed due to positive COVID-19 status. Given the known challenges of providing robust therapeutic options on a medical floor, coupled with the limited resources to address behavioral dysregulation, and further complicated by the precautions necessary due to COVID-19, it has been imperative to seek creative solutions . A conscious effort has been made to limit prolonged exposure for staff and the amount of entering and exiting of the negative pressure rooms. While certainly not all-encompassing, the hybrid role has served well in the following ways: (a) allowing for simultaneously coordinated exams with the pediatric hospitalist attending in person and the child and adolescent consult-liaison psychiatry attending by telemedicine, (b) providing flexibility in fulfilling patient care responsibilities across specialties based on staffing needs, (c) having someone trained in behavioral management available to guide discussions on PRN medications and non-pharmacologic strategies, (d) interpreting medical findings in the context of complex psychotropic medication regimens, and (e) troubleshooting issues that arise with the budding telemedicine system that would otherwise lead to disruptions in care.
While still in the early phases, it has been encouraging to note that personal protective equipment has been able to be conserved, 1–2 pediatric residents have been able to be re-distributed to serve the needs of other patients, the child and adolescent consult-liaison psychiatry has predominantly been able to function via telemedicine, care coordination between the medical and psychiatric hospitals has been strong at a critical time, and reliance on PRN medications for behavioral management has largely been avoided. As the COVID-19 situation continues to evolve, the anticipation is that the hybrid role will continue to be adjusted. Depending on patient census and hospital coverage needs, it is possible that additional Triple Board residents could be recruited to play similar roles. The unpredictability of what is to come makes adaptability key, and Triple Board physicians are well suited for the challenge.
At a time when fear of the unknown is pervasive, the familiarity of Triple Board physicians with a range of systems can be an asset. Although the current literature base suggests that the disease burden of COVID-19 in children generally appears to be low, Triple Board physicians have the institutional knowledge, prior interface with providers on the medical floors, and comfort with integrating multiple approaches at once to contribute in meaningful ways . Furthermore, in light of the risks of infection transmission in clustered groups, it is not outside the realm of possibility that outbreaks will unfortunately start to be seen on inpatient psychiatric units, in residential facilities, and in therapeutic group homes nationwide. These venues may offer Triple Board physicians the opportunity to further transcend the typical silos of mental and physical health and limit the exposure risks of other staff members. The avenues to contribute will be many, and if utilized creatively, Triple Board-trained physicians may be called upon to serve in even more innovative ways than originally envisioned years ago.
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The author would like to thank Dr. Jeffrey Hunt for his review of this manuscript and Drs. Emily Katz and Patricia Poitevien for their invaluable support.
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The author states that there is no conflict of interest.
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Raj, A. The Unexpected Perks of Triple Board Training: COVID-19 Response. Acad Psychiatry 44, 691–692 (2020). https://doi.org/10.1007/s40596-020-01297-8