The medical students soon after finishing their post graduation are often a little confused and unsure, though bubbling with acquired knowledge, energy, and ambition. Many are uncertain about what to do next? Those who want to work in a medical school look for jobs, which are not many. Having spent most of their 8-9 years in a teaching institute as a student, they know what to expect there. The majority opt for private practice hoping for a future which gives them professional satisfaction, financial security, social status and enough time for their family and emotional needs. Indeed, a tall order in any profession. I would like to throw some light on various issues a practicing pediatrician is likely to face.

Most take this path as it looks the easiest. One can set up a practice in one’s own house and can function with minimum expenses. Practicing General Pediatrician’s emoluments are the same or slightly better than that of a General Practitioner (GP) with no post-graduate qualification. However, his social and professional status is better. I feel the best part of such a practice is that one is dealing with young patients and young parents. Children are always a delight with no pretences about their illness. Lady pediatricians have an added advantage that they can share the concerns of the mother much better, being in the same age group with similar problems. The major part of a pediatrician’s practice consists of routine check ups, immunizations and the care of common illnesses like fever, respiratory infections, diarrhea etc. Most of these illnesses are self limiting. Lucky ones get admission facilities in a near by nursing home or hospital. Luckier are those who are attached to a busy obstetrician for resuscitation of her patients deliveries. It is a great advantage as they have a continuous supply of patients from the obstetrician.

House visits are almost unheard of in big metros due to long distances but fairly common in smaller towns. A house visit, though time consuming, brings the family closer to the pediatrician who also becomes a counselor and a friend whom they can trust and confide in their personal and family problems. It also gives the pediatrician an opportunity to take time away from his busy practice and socialize while earning.

Most young doctors like to settle in the big cities because of its glamour, professional opportunities and facilities for medical care and education for the children and the family. In metropolitan cities, a suburb is a better choice. Choose a new colony which is developing, as the families in the area have probably left their previous pediatrician at a faraway distance and are likely to take up the one who is near their home. Another choice is one’s own hometown or a bigger town near the hometown. The back up of family and childhood friends in all matters like money, space, accommodation and contacts is a big help for a beginner. Those who have the means may start a small nursing home in their hometown. Unfortunately, the glamour of the big city is too much to resist. Over the years I have observed that those who opted for their native places and peripheral towns have done much better and struggled far less.

An ideal clinic would be one which is situated in one’s house, nursing home, polyclinic or a hospital. It should have good approach road and ample parking space, otherwise the neighbors would hate you for the inconvenience.

The clinic should have a well-ventilated examination room which has a good source of daylight. The waiting and reception area should be spacious as every child is accompanied by parents and often siblings and other members of the family. Children also need space to play and walk around to keep themselves busy. If the space permits a small treatment/immunization room can be a real help and also used for observation of sick children.

It is desirable to have a receptionist and a trained nurse if the practice is large. Professional fees depends on the area of practice. Posh area clinics in the upper income segment have usually higher fees and fewer patients. Lower fees in a crowded neighbor-hood attracts larger number of patients. To enhance one’s emoluments one may have a collection centre and also dispensing facilities.

Most pediatric practitioners have a walk-in clinic which means that a patient comes without appointment during consulting hours. It is difficult for patients to keep appointments in big cities because of traffic jams and long distances. In smaller towns, they are not used to the idea of appointments. Disadvantage of a walk-in clinic is that the doctor cannot give enough time to each patient. At times, one may be sitting without a patient and at another time there are so many that it is difficult to give proper attention. Ideally, one should have an appointment system whenever possible.

In today’s world of increased connectivity and the advent of mobile phone, one can give extra service to the patients wherever they are and whenever they need you. But it also puts extra burden on the pediatrician as many calls are repetitive and on issues of drug dosages for fever, diarrhea, vomiting etc. The doctor has to train his clients that a pediatrician is a source of help during an emergency but not a railway information center as some patients would like to believe.

Burnout is "a state of physical, emotional and mental exhaustion caused by long term involvement in situations that are emotionally demanding."(1) This is a situation in which a pediatrician feels emotionally and/or mentally exhausted due to a routine, such as seeing patients with same cold, cough and diarrhea, day in and day out, without any professional challenge. Initially, most pediatricians would have only this type of practice along with resuscitation, immunization and routine check ups. Only an established and well-known pediatrician would get referrals and patients with rare and undiagnosed illnesses, which challenge the intellect and knowledge.

In earlier days, and even now in some of the smaller towns, where the pediatrician makes house visits, a socially alert doctor can treat it as an outing. One can have a cup of tea or have a drink and a little chitchat with the family members. It helps to prevent a burnout. However, it is better to develop a hobby, take active part in sports, join an organization, a nearby club or get involved with some social cause or do advocacy for a cause.

Advocacy for a cause one believes in will not only help one in preventing ‘Burnout’ but would also help the society at large. If it is for the cause of children, all the more better e.g,. street urchins, disabled child, school examination system, consumer protection and environment issues to name a few. IAP has many ongoing projects to choose from. If advocacy doesn’t interest you atleast improve your academic knowledge by attending CME, workshops, guest lectures. Learn a new skill; music, painting, gardening or even cooking. There has to be something more than seeing patients day and night. Take a holiday with family and friends. A short break of 2-3 days would please your spouse and children also. ‘My patients would suffer’ or ‘I cannot afford to leave my patients’ is only an excuse. Nobody is indispensable(2).

Computers are a must for the younger generation and also recommended for the seniors. They are used for keeping an immunization record and to send a recall for a follow up/ check up. Studies have shown that patients prefer computer-generated prescriptions over the handwritten and often illegible prescriptions. However, many doctors feel that while writing the prescription by hand it gives them an added opportunity to interact with their patients. Communication is more personal. Software for day-to-day record keeping of ‘clinic’ patients is improving but not many pediatricians are comfortable with what is available at present. Accounts can also be kept on computers. If one has the e-mail addresses of the patients, one can send the important information on various health issues from time to time whether it is bird flu, dengue, meningoccocal meningitis or any other health issue in the community. Internet, if used discretely is a useful source of unlimited information for both doctors as well as patients. If you do not seek information on the internet, chances are that your patient will. Disadvantages of the use of computers include the initial capital outlay for hardware and software, with additional costs in updates. Further resources may be required, including administrative staff, space and repairs. Clinic staff may not be supportive and may not engage with training(3).

A medical group is defined as three or more physicians formally organized as a legal entity in which business, clinical and administrative facilities are shared(4). However, in India, even two pediatricians can work together as a group. Most pediatricians in India have solo practice whereas in western countries, group practice is fairly popular. Solo practice is more personalized, professionally satisfying and remunerative. The problem is that it is very demanding and restricts the doctor’s academic, family and social activities due to paucity of time.

Group practice on the other hand has an advantage that one can share one’s night calls, emergency call and even telephone consultations. The group members can consult each other when confronted with a difficult case and also have academic discussions from time to time amongst themselves. There is more time for family and social life. However, the patients may not appreciate consulting a different doctor in an emergency. One has also to share the earnings with different members of the group. This is possible only if proper accounts are maintained(5).

Litigation is fairly common amongst the surgical specialties. However, the neonatologist, intensivist and oncologist amongst the pediatricians are also prone to litigation. Failure to communicate adequately with the patients and their family is the commonest cause of dissatisfaction leading to litigation. Lawyers and jealous colleagues are the ones who instigate the patient. First and foremost, one must have medical indemnity insurance which should cover all the places of work-clinic, nursing home and hospital. The medical records of visits to the clinic and progress notes during admission should be legible, regular and give reasons for any changes in management. In the court of law, written medical records is the main evidence; what transpires verbally between the patient and doctor is not very important as there is no proof of that. If somebody is unhappy and sends a complaint, meet in the office and pacify in person or through intermediaries but do not respond or justify your viewpoint in writing. Any reply written by the doctor to the patient or his lawyer can be used against him in the court of law. Do not panic and instead consult IAP medicolegal cell or any other similar group for their opinion. If there is a pending bill against the patient and by collecting it one may aggravate the situation, in that case one may waive off the bill to pacify the client but one must show it in one’s accounts books as a pending bill, otherwise waiving off the fees is shown as evidence of admission of negligence.

Most of the pediatricians prefer to continue with their general pediatric practice and also develop a superspecialty. Once, they have enough practice in the superspecialty, they may consider leaving the general practice. Some pediatricians, especially those who have spent many years in their training for the superspeciality would like to practice only the superspeciality from the very beginning. Superspecialists need lot of patience not only during their training but also at the start of their practice as it may take anywhere from 2-5 years to become economically self sufficient. There are not many avenues for training as a super specialist, so not only one needs lot of motivation but also an opportunity to get trained. Very often, one has to go abroad (commonly UK, USA, Austarlia). One has to pass many examinations to get the necessary certification for working in a particular country. Lately, the facilities for super specialty training in India are increasing. Explore all the avenues for training before finalizing your decision.

Neonatology is the most popular superspeciality in our country. There are plenty of facilities for training neonatology in India itself. Expertise in neonatology and resuscitation enhances the opportunity for attachment to a nursing home or a hospital. Practice is easier to establish. However, exclusive neonatolgy practice is limited to neonatal intensivists in big hospitals only.

Pediatric Intensive Care is a young, but very popular superspecialty in our country. Training in this specialty facilitates attachment to a big hospital. Patients admitted to intensive care facilities invariably like to have their follow-up with the same consultant whenever possible. Reputation and practice gets a boost. However, it is a very demanding job with a high burnout rate.

Hematology Oncology is also very popular. The IAP chapter in this specialty has been very active. It has helped to spread a concept of "shared care". It’s a large specialty covering thalassemia, hematology, oncology and various other hematological complications. It is also financially lucrative, specially the chemotherapy management of oncology. However it needs extensive training, is labor intensive and there is far more litigation especially in oncology. Pediatric hematology oncologist can pursue their specialty exclusively without doing any general practice.

Neurology deals with lot of emergencies, developmental pediatrics and intensive care. It generates good income but one needs a prolonged training period. There are very limited facilities for training in Pediatric Neurology in our country.

Developmental Pediatrics is essentially a teamwork. A developmental pediatrician also needs a psychologist, neurologist, occupational therapist, special educator, speech therapist and social worker. One needs lot of space and time to pursue this superspecialty and has to be very dedicated as it is not very remunerative financially in India at present. Abroad the fees are more generous and paid by the state or insurance companies.

Pediatric Gastroenterology, Endocrinology, Rheumatology, Nephrology, Pulmonology, Allergy and Asthma are the specialties where most people would like to do general practice also. On their own, these specialties are not financially remunerative. However, these specialties enhance the scope for general practice and add to the individual’s status and income.

Adolescent Medicine is picking up in India, as there is an increase of ‘life style’ diseases in the community. One should keep a suitable time and place for adolescents, as they do not like to be seen with small children. One has to be non-judgmental and keep the confidence of the adolescents. Besides immunization, a lot of counseling on various issues including eating habits, body image, sexuality and growth is required.

There was a time when more than 90% of pediatrician’s practice consisted of managing infectious diseases. Now that most of the infections are controlled, pediatricians can devote more time to other issues during consultation. Besides physical examination and immunization of preventable diseases, one should check the growth and discuss nutrition, accident prevention, TV viewing, school, outdoor activity, social problems, and environmental issues.

To give better services, one should keep proper records, preferably on the computer, have a recall system as most parents forget the immunization after the child is 2-3 years of age. Discuss Health issues, education materials, keep some low price gifts for children. One could also have a collection center and medicine dispensing facility if there is enough space in the clinic. This would not only help the patient to have quality investigations and genuine medicines but also save their time as all the services are available under one roof. Moreover, it is an extra source of income for the pediatrician.

I personally feel, family medicine training is a good addition for general pediatric practitioners. A little training in gynecology and adult medicine and the pediatrician can extend her or his practice to the young parents of the child also. Adult physicians and superspecialities keep on dabbling with children even in institutions where pediatrics is well established. It is high time that pediatricians also extend the age group of their patients, albeit only in situations where they feel comfortable.

I would like to conclude that pediatrics is a wonderful specialty, which takes care of the doctor’s emotional, social and intellectual needs. It is labour intensive but easier to establish as compared to some other medical specialties. Monetary returns are adequate but less. Dealing with young children is always refreshing.

Competing interests: Author is a well-established and renowned pediatric practitioner.

1. Pines A, Aronson E. Career burnout. New York: Free Press, 1988.

2. Johnstone C. Strategies to prevent burnout. BMJ, 1999; 318: 2.

3. Parkin A. Computers in clinical practice: applying experience from child psychiatry. BMJ, 2000; 321: 615-618.

4. Havlicek PL. Medical group practices in the US. Chicago IL; American Medical Association; 1999.