Intended for healthcare professionals

Editor's Choice

Are you ready for “collaborative health”?

BMJ 2017; 358 doi: (Published 06 July 2017) Cite this as: BMJ 2017;358:j3257
  1. Fiona Godlee, editor in chief
  1. The BMJ
  1. fgodlee{at}

“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.j3203): 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.”

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