Mumbai is certainly a rare city where a cosmopolitan atmosphere combines with a huge population, increased environmental pollution and increased respiratory morbidity. This situation is not welcome for most patients with chronic respiratory disease, and also puts a huge strain on the private and public health services.

In this context, one should look back about 10 to 15 years ago when private practice in Mumbai was strong and established (even as it is today, though a bit different now). At that time, the patient-doctor relationship was strong, most regularly used medication was not horrendously expensive, and with a fair amount of time being given to the patient, the bonding that occurred between the patient and the doctor turned out pretty strong. A one-on-one relationship was being built based on faith, understanding and cost-effective, appropriate treatment. With long queues at public Hospitals, along with overcrowding, the private sector always looked more enticing to even the averagely affording patient.

Things have changed today. Medicine has become more evidence-based and with that comes more investigation and more caution (sometimes needlessly) when managing patients. The doctor today bases a lot of his treatment on current guidelines. Newer guidelines reflect modern medicine’s approach to medicine. The clinical aspects of disease are important, but significant emphasis seems to be directed to a more investigation-based approach. This has its advantages and disadvantages. For example, in a disease like COPD (Chronic Obstructive Pulmonary Disease), the clinical signs are a hallmark of diagnosis. Just simple inspection of a COPD patient’s chest gives you tremendous information (more than auscultation can even offer!). The modern-day approach to COPD diagnosis stresses on spirometry, a simple lung function test. Critics would argue that this is making the diagnosis of COPD more complicated. But I would beg to differ. Spirometry is a very simple, underutilized investigation that not only helps to diagnose COPD, but also grade the severity of the disease. This is extremely important, in that most patients today have a lot of questions pertaining to their disease, especially regarding prognosis. The objective evaluation that Spirometry offers allows the physician to grade the severity of the disease much more accurately and therefore prognosticate much better.

This is modern medicine in private practice. Better understanding and better objective evaluation. And added to that crucial ‘time’ spent with the patient in reassuring him or her about various fears and concerns on the disease concerned. It applies to any disease. Imagine Diabetes not being managed with blood sugars and glycosylated Haemoglobins (not withstanding regular eye and renal checks), or imagine Hypertension not being managed with sphygmomanometry and often 24-hour ambulatory readings. Finally imagine managing lipid disorders without a detailed lipid profile. It has almost become the norm today. This is preventive medicine at its cutting best. It costs a little bit more, but it gives that huge increase in quality of life - and that’s what the whole world wants today. More so in the West.

To add to that, today’s patient is not the patient of 15 years ago who rarely asked questions and would cower down when the doctor looked sternly at him or her and said “Do you know or I know what’s wrong with you?” that patient has changed to a more informed patient (what with modern television, the internet and the media) to one who asks more questions (much to the irritation of ‘some’ senior doctors!) and who probes the prescription of the doctor to every single investigation and drug prescribed. This is excellent for the well-informed doctor who would be only too glad to answer all the queries, but puts a challenge (not difficult to surmount) for the less-informed practitioner.

More and more patients ask for detail. More detail doesn’t mean more investigation, but better understanding. Communication skills among modern practitioners have improved immensely and this is where the gap between too much and too less investigation or treatment can be bridged successfully. Good communication is taking modern-day physicians a long way ahead of what they used to be. The pity is that communication is still not a subject in medical schools, which I strongly feel it should be. Here is a profession where ‘talking to people’ is a daily requirement, and sadly many doctors (despite being academically excellent) fail in this final thrust with the patient.

Yes, it has resulted in medicine becoming a bit more expensive. But I feel that’s the tip of the iceberg. The improvements in technology (both laboratory and infrastructure oriented) have increased costs, but cost-effectively, if used judiciously.

The future of medicine is certainly preventive medicine and not preventive interventions. Going the latter way is likely to hazardously increase costs and be needlessly expensive and often unnecessary to most patients.

Private practice in Mumbai is excellently geared towards preventive and judiciously practised medicine. With a wide variety of specialists and adequate infrastructure, Mumbai can go the right way ahead and stay there, provided medicine is practised evidence-based, and primary care providers are continuously educated on newer guidelines and newer methods to improve patient adherence to the right treatment regimens.

Chest Sp. Bombay Hospital and Research Medical Centre, New Marine Lines, Mumbai 400 020.