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in a lighter vein

Indian Pediatr 2014;51: 407-408

The ABCD of Pediatric Practice

Sharmila B Mukherjee

Department of Pediatrics, LHMC and KSCH Hospital, New Delhi, India.
Email: theshormi@gmail.com

The ultimate goal of a Pediatric post-graduate curriculum is the creation of doctors capable of successfully dealing with child health problems. By the end of training, everyone can state the ABCD of resuscitation, but very few have heard of the ABCD of pediatric practice. This stands for Appearance (A), Behavior (B), Competence (C) and Drama (D)! They are core competencies required for impressing parents and dealing with them artfully. The effect of mastering them is directly proportionate to professional success. Regretfully, their importance has not been recognized by academicians and curriculum planners. Practical awareness dawns on most pediatricians gradually over the years – by learning from personal experience and observing more successful colleagues.

A, B, C, and D (in descending order of importance) are essential for laying the foundation of the doctor-parent bond. They empower a pediatrician by enabling him/her to impress parents resulting in continuous follow-up from infancy to adolescence (and sometimes even the next generation!). Building the relationship begins with the doctor appealing positively to the parent (dependent mostly on A and a little on D). It is further nurtured primarily by positive behavior, and secondarily by competence. Each component will be discussed briefly in the following paragraphs.


This comprises of attire and demeanor of the pediatrician as well as how appealing and comfortable the décor of the establishment is. Attire can be formal, semi-formal or casual and is gender-specific (Table I). In Government hospitals, formal attire is mainly adopted by senior faculty or is occasion-based (lectures, paper presentations, conferences, examinations). Semi-formals are worn usually by junior faculty except in the afore-mentioned instances. Casuals are worn by residents to cope up with strenuous 24 hour duties, and also because of lack of laundry services in most hostels. This is acceptable as long as social norms are respected (no unwarranted body exposure) but is generally frowned upon afterwards. Women in government hospitals should opt for minimal make-up, less expensive clothes, subtler jewellery and flat heels. This helps in establishing rapport with the disadvantaged populations they serve as there is no obvious disparity in circumstances. Ill-conducive working environments (mud, dust or waterlogged areas that need to be waded through or jumped over) also dictate one’s decision. In contrast, formal attire is worn by almost everyone in private hospitals due to the strict dress codes (ties even in summers for men!) and much cleaner surroundings. Here, it is important to appear financially successful and at-par with the clientele to instill confidence and faith in them.

TABLE I Description and Levels of Appearance, Behavior, Competence and Drama

Appearance (attire) Behavior Competence Drama
Female Male Levels of composure, Parental satisfaction Ability to over exaggerate,  
patience and politeness levels with treatment convince and bluff parents
in trying circumstances and care
Formal Formal Level 1 Level 1 Level 1
Sari, Salwar Suits with  complete composure, Satisfied Parent impressed and
Kameez, Formal ties, shirts, maintaining patience and awestruck
Western suits pants remaining polite
Semi-formal Semi-formal Level 2 Level 2 Level 2
Salwar Kameez, shirts, pants Slightly ruffled,  slightly  Neither level 1 or 3 Neither level 1 or 3
trousers, tops impatient and occasionally
becoming impolite
Casual Casual Level 3 Level 3 Level 3
Salwar Kameez, T shirts, jeans completely ruffled, loses Dissatisfied Parent unimpressed and
kurtis, T shirts, patience completely and not  awestruck
jeans rude or aggressive


This encompasses facial expressions and body language (pleasant and positive), approachability (more for juniors and slightly less for seniors) and ability to respond appropriately in stressful circumstances. These range from brawls, physical altercations, hostile family members, extremely high expectations of attendants, and having to answer questions based on information that is anecdotal or internet-derived. Levels of competency also differ according to setting and seniority. Least desirable behavior is exhibited mostly by residents of government hospitals. This is understandable due to associated environmental (low doctor-patient ratios, more critical patients, more apprehensive family members and barely existent security) and psycho-social (lower patient educational levels and hence understanding) factors. Residents of private hospitals perform better due to mandatory Personal-Relationship orientation programs, less stressful situations and better working conditions. Government hospital faculty and consultants of private hospitals are not exposed to such situations, as frequently, as their juniors tend to serve as shields. However, when they do, they are better at defusing the tension due to the ability to remain calm and polite, and due to the intrinsic aura associated with their designation!


Contrary to popular misconception, this component is not dependent on how much you know or can do, but rather on personal outpatient attendance and admission rates. An indirect indicator is also the ability to induce high levels of parental satisfaction. In private hospitals, parental satisfaction is considered sacrosanct as it ensures more visits, wider recognition, increased clientele and financial returns. Despite having to pay exorbitantly for services, parents are more satisfied with the level of care due to better standards of comfort, cleanliness, cafeterias with branded outlets and lack of overcrowding. Satisfaction with treatment is also higher as cure is usually inevitable and mortality unlikely, given the relative stability of patients. In contrast, patients frequenting government hospitals are more disgruntled due to the long queues and lack of facilities and comfort. They are usually not appeased with explanations doled out for not medicating (e.g. diarrhea will improve with only ORS and antibiotics are not required in a cold). However patient satisfaction does not really matter as there is no dearth of patients, no monetary loss if patients defect and salaries remain unchanged. Competence of government hospital faculty is judged by numbers too but the parameters differ. ‘Numbers’ here refer to numbers of conferences attended, international papers presented, papers published, committees one is a member of, and visits to the head of the institute’s office or Ministry.


This includes the ability to: over-exaggerate seriousness of illness (a cure means you have saved the patient from death!), convince parents for admission (when domiciliary management would have sufficed) and use actually simple, but apparently sophisticated, equipment in such a way that it appears awe-inspiring and fear- inducing. A few pediatricians are actually naïve enough to object to this on moral grounds. However, even they can still be successful by over-compensating with A, B and C.

To conclude, I have attempted to present theory in a structured way so that related psychomotor and communication skills can be developed by the readers so that they can achieve success. I strongly urge concerned authorities to incorporate this topic into the pediatric curriculum. Apart from benefiting the trainee, it would also ultimately serve the community. Successful pediatricians mean better child health, happier parents, and a more prosperous nation!

Competing interests: SB has tried most levels of ABC and D during her evolution from a trainee pediatric resident to a Professor of Pediatrics in a Government Medical College and Hospital.

Funding: ‘Art of living and practicing’


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