Are you ready for “collaborative health”?

时间：2017-07-06

发布：Fiona Godlee, editor in chief，The BMJ

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“A reform is a correction of abuses; a revolution is a transfer of power.” So said the Victorian essayist Edward Bulwer-Lytton. Patient centred care began as a correction of abuses, says our essayist Michael Millenson (doi:10.1136/bmj.j3048), a response to patients being treated like “imbeciles and inventory.” It is now a mix of partnership and paternalism, he says, and the real transfer of power is yet to come. He calls this result “collaborative health” and says it will shape 21st century medicine. So we’d better be ready.

The seeds of the change are already sown in the digitisation of all aspects of life, at least in rich countries. Increasingly people can source information widely, integrate and manage their financial, social and domestic, and medical spheres, and decide who and who not to share information with. In this new world the doctor is likely to play a smaller part in a person’s recovery and wellbeing, or none at all. Three core principles will shape this future, says Millenson: shared information (opening up the electronic health record), shared engagement (including flexibility in how much the patient wants to take part in decisions), and, most challenging of all, shared accountability (replacing medical authority with mutual trust).

In this revolution, things could go well or badly. Going well would mean better health, better healthcare, and more autonomy for patients, with the potential to turn us away from ever more medicalisation. But going badly is also possible. Digital datasets may be used to manipulate, coerce, surveil, target, and manage people, as well as to perpetuate or even widen social injustices and disadvantages.

This less good future is what worries Iona Heath (doi:10.1136/bmj.j3181): biometric sensors harvesting big data to trigger algorithms and offer possibilities for remedial action, causing distress and serving the interests of the medical industrial complex. “Any healthcare professional who has been seriously ill knows that information . . . can often aggravate fear by suggesting a range of possibilities that might not [otherwise] have come to mind,” she says. Gerd Gigerenzer is equally scathing (doi:10.1136/bmj.j3159), not only about the “fanfare and hype” of big data but the statistics being churned out.

Millenson ends on a positive note, however. The world will still need doctors, he says, and there remains great value in professional expertise rooted in ethical and legal traditions. “Accepting a less central role may feel at first as if collaborative health is shrinking the profession’s importance. In reality, accepting true partnership will profoundly expand the profession’s influence in the days to come.”

BMJ 2017; 358 doi: https://doi.org/10.1136/bmj.j3257 (Published 06 July 2017)
Cite this as: BMJ 2017;358:j3257

Healthcare for the many

时间：2017-06-29

发布：Theodora Bloom，executive editor，The BMJ

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Do clever people live longer? Numerous studies linking IQ to health outcomes indicate that they might, and now a large longitudinal study reaches a similar conclusion (doi:10.1136/bmj.j2708). In their long term study Catherine Calvin and colleagues followed tens of thousands of people born in Scotland in 1936 and found that higher IQ at school age correlated with lower death rates from many causes, in women and men. The association was strongest for respiratory disease, coronary heart disease, and stroke. In their linked editorial (doi:10.1136/bmj.j2708) Daniel Falkstedt and Anton Lager point out that, given the strong link between these conditions and smoking, socioeconomic status may underpin much of the finding, but it remains to be seen whether this is the whole story.

WHO defines four main dimensions to the social determinants of health: economic, political, social, and cultural. Inequality in any of these can lead to social exclusion and health inequity. The 0.6% of the UK population that identifies as transgender (according to healthcare records) may experience just such exclusion and inequity. Clinicians’ feelings of inexperience in this area should prompt them to learn more, rather than avoiding the issue, says James Barrett (doi:10.1136/bmj.j2866). A group of transgender patients remind their healthcare providers that “how trans affirming you are has a direct impact on my health outcomes” (doi:10.1136/bmj.j2963). Sometimes patients will see their GP for referral to a specialist clinic for gender dysphoria, which should be done promptly and respectfully. But transgender people consult GPs and specialists about unrelated problems, and “a person’s change of gender role is rarely clinically relevant and does not need to be mentioned unless it is,” says Barrett.

All four of WHO’s dimensions affect the more than five million refugees from the war in Syria now living in neighbouring countries, including more than three million in Turkey. Providing healthcare for such a huge displaced population requires creativity. Abbreviated localised training for Syrian doctors and nurses in southern Turkey is one approach. It could provide healthcare workers who can break down language barriers and are familiar with diseases prevalent in refugee populations. Scaling up from a pilot study might yield hundreds of willing healthcare workers in the many Turkish cities with large refugee populations. But what will be the effect on refugees’ health and on the host country’s health services? And how will the host country’s professionals respond to their new colleagues? Despite such uncertainties, Vural Özdemir and colleagues argue (doi:10.1136/bmj.j2710) that we must explore all options, because huge numbers of refugees are likely to remain displaced for many years. Meeting the needs of society’s most vulnerable people will test the political will of all nations.

BMJ 2017; 357 doi: https://doi.org/10.1136/bmj.j3122 (Published 29 June 2017)
Cite this as: BMJ 2017;357:j3122

Give a voice to the voiceless

时间：2017-06-22

发布：Kamran Abbasi，executive editor，The BMJ

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Rudolf Virchow’s investigation of a typhus epidemic in 1848 identified a root cause: “The power of the aristocracy, propped up by the church.” Big business is today’s aristocracy, politicians and the state today’s church. In society’s pursuit of wealth and profit, it is poor people who carry the greatest burden of disease, whose deaths are most likely when fire engulfs a tower block, the levees break in New Orleans, or a Titanic sinks.

After last week’s fire in London’s Grenfell Tower Martin McKee recalls Virchow to urge us not to ignore the political and commercial determinants of public health (doi:10.1136/bmj.j2966). Inadequate safety measures, despite warnings from residents, contributed to and probably caused 79 people to be dead or missing. This was a political failure leading to avoidable deaths and, says McKee, “it is impossible to achieve a comprehensive understanding of events such as Grenfell Tower without confronting the political determinants of health and challenging the forces that shape them.”

One solution might be to put an end to high rise living. An area might be regenerated by demolishing a “sink estate” that includes high rise buildings and replacing it with luxury apartments and low rise, affordable housing. But this would be a form of “social cleansing,” explains Anna Minton (doi:10.1136/bmj.j2981). The volume of new affordable housing is invariably too small, with a net loss of 8000 social homes in London in the past decade. Indeed, most residents “love” their tower blocks, but their experience is sullied by forces outside their control, from broken lifts to lack of security. The issue is less with the tower blocks themselves and more closely related to socioeconomic factors. “At a time of huge worry and uncertainty,” writes Minton, “threats to demolish people’s homes cannot be helping.”

Inequality and the vulnerabilities of poor people find an echo in our research section. Bochen Cao and colleagues (doi:10.1136/bmj.j2765) grouped countries by Human Development Index and examined the effect of variation in cancer death rates on longevity. Countries with the greatest resources benefited most in life expectancy as a direct result of improving cancer mortality. In an accompanying commentary (doi:10.1136/bmj.j2920), Mary Louise Tørring acknowledges the inequalities at play, and proposes priority funding for poor countries and for women, but wonders whether these new findings “might also prompt us to think more about cancer as a natural ceiling on human longevity rather than as a rising epidemic.”

A key message here, from a devastating fire in a London tower block to patchy global progress in longevity, is that health professionals have a responsibility to ensure that the weak are not silenced, ignored, or discounted. We must, in the words of McKee, with a nod to Virchow, give voice to the voiceless.

BMJ 2017; 357 doi: https://doi.org/10.1136/bmj.j2996 (Published 22 June 2017)
Cite this as: BMJ 2017;357:j2996