These days there is continuous discussion on ways to improve the efficiency, quality, and cost-effectiveness of healthcare. I would argue that one of the most neglected and important ways to improve our healthcare delivery and innovation is by opening access to research. "Open Access" is the free, immediate, unrestricted availability of high-quality, peer-reviewed scholarship over the Internet - combined with the rights to use this information to its fullest possible extent.
So as a future physician why does open access matter to you? Here are 6 good reasons...
Ever start searching for resources to write a paper, find the perfect article online, only to click on the link and find your school does not subscribe to that journal? Even then, perhaps you thought about purchasing the article only to find that it would cost $15, more than a month's subscription to most journals... This happened to me yesterday on my internal medicine rotation. I had a patient who had developed gastrointestinal (GI) bleeding but was on medications to thin his blood due to heart problems. This is a risky but very common medical situation. So I began looking up papers on the topic as the management is very controversial... I found the perfect paper which looked at outcomes of stopping vs. continuing blood thinners after a GI bleed. It had just been published 1 month ago, and in fact the authors are faculty at my medical school... and yet I was unable to access the article.
The gap in access to up to date information diminishes our ability as students to educate ourselves. Furthermore, this gap in access is likely to grow. In the current era of budget cuts at public universities and hospitals, expensive journal subscriptions make an attractive target of cost savings. So where does this leave student education? With an even larger gap in access, the majority of students will be unable to fully access information crucial to our education.
2. Patient Care
Let's go back to that article I found yesterday and my patient with GI bleeding... I was not the only person unable to access the article, my attending physician could not access the paper either, thus we lacked the most up to date information on how to manage our patient. Either we could stop the blood thinners which will decrease the patient's chance of bleeding but puts him at an increased risk for a clot and heart attack, or we could continue the blood thinners and risk him bleeding into shock. This is not a trivial decision and this topic is the focus of very active medical research, so why are we forced to wait 12 months or longer until our institution has access to this information?
This gap in information access is even larger in private practice where doctors often only subscribe to a handful of journals due to cost restrictions. This problem magnifies once again in the setting of a community health clinic or rural areas, and this information disparity is likely to contribute to the health disparities in these areas.
So imagine being the authors of this paper on GI bleeding. Do you think they want others to read their article? Of course! Research authors really really want us to read the work they produce. Researchers do not benefit from publishing unless their articles are read. There is not even a financial benefit to researchers when you buy expensive journal subscriptions or that $15 article. Research thrives on the sharing of ideas, and research careers are made by publishing widely read articles that inspire other people’s research or change the way we practice healthcare. For the author, the goal of publishing an article is to move patient care or medical innovation forward, not to have a list of unread articles serving as bullet points on a resume. Increasing open access to research allows for a free exchange of ideas serving both the goals of the researcher and the benefit of students and patients...
4. Patient's Rights
Of course, medical students and physicians are not the only ones who benefit from access to research. Patients and their advocates also deserve access to the corpus of medical research. Imagine you are the spouse of my patient with a GI bleed. What's the first thing you would do when the doctor told you what was wrong? You'd want to learn more about it. These days if you don't have a nurse or doctor in the family to query, you turn to Google... but you'll almost certainly find yourself unable to access the vast majority of journals without a subscription. So what are your alternatives? Wikipedia? Yahoo Answers? Wrongdiagnosis.com? None of these sources provide reliable information to patients. In fact, I would argue these resources only increase the duress of patients and families by providing views that often contradict the information provided by the doctor without providing an evidence base. However, their doctors, who would like to provide them with accurate sources of information, are also hand tied by the lack of open access.
5. Global Health Equity
Taking another step back, now outside of the microcosm of the American hospital filled with doctors, patients, medical students, and researchers. If you think access to up to date research is difficult to come by in a rural community health clinic, try going to Kenya. Even physicians who work at academic institutions are faced with small budgets and an increased medical demand, making thousands of dollars of journal subscriptions completely unfeasible. Open access to research would be another step towards reducing steep health disparities in developing countries.
On the sunny coast of Kenya, researchers at my medical school work with Kenyan doctors to study malaria and HIV transmission and prevention. The vast majority of research on these diseases of the developing world is published in American or European journals, despite the fact that the findings primarily impact people in developing countries. The steep price barriers of these journals prevent physicians in countries like Kenya from accessing this research, even when the research subjects are sometimes their own patients! Rather than having an immediate impact on patient care, the cost barriers of current system means that evidenced-based practice may take years to become the standard in countries without access to information.
A quick aside....
So at this point, you are hopefully thinking these are fairly strong arguments for opening access to research, but there must be some reason this system is in place, right? Well, some journals argue that high prices are necessary to cover journal costs. But guess what, the journal industry has some of the highest profit margins of any business in the world, much higher than other book publishers:
What's even more startling is how the research review process works.
Step 1: Researchers submit their articles to journals, often paying a fee to the journal for submission.
Step 2: Journals get other researchers to review articles for free as a matter of prestige.
Step 3: When a journal accepts an article for publication it generally claims all future publishing rights on the article.
Step 4: The journal pays for the costs of formatting, print publishing, and so forth -- costs which are uniformly decreasing as publishing switches from print to online formats.
Step 5: The journal now accrues all of the profits from these articles via subscriptions or individual article purchases.
Given that both the supplier and the purchaser pay a fee to the journals, and the reviewing work is often done for free, you can imagine why profits are so high....
6. Public Investment
Here is your icing on the cake... guess who paid for all of this research in the first place? You did! The vast majority of medical research is funded by the National Institutes of Health, a federal organization funded by you, the taxpayer. Why do we invest our public dollars in research? To improve patient care and medical innovation, of course – an outcome that only happens when students, physicians, researchers, and patients have open access to research.
Take your pick, however you choose there is a reason to support open access to research... so what can you do about it?
April 7, 2011 marked the third anniversary of the National Institutes of Health (NIH) public access policy, the first open access policy enacted by the United States Federal Government; it has delivered free and open access to over 2 million full-text articles in just three years by requiring all the publications of all researchers supported by the NIH be made open access within 1 year after publication. As a result, PubMed Central sees nearly 500,000 unique users every day and has served as an invaluable resource for medical students, physicians, and researchers. However, this policy still delays access to research by a year and does not include other federal funding agencies such as the Centers for Disease Control or the non-medical research arms of the federal government.
This milestone is a critical opportunity for students to join other public access advocates in pressing for the expansion of the successful NIH policy to other federal agencies. Please join students and researchers across the country in calling on key policy makers to take advantage of this occasion by sending emails to the heads of the Department of Health and Human Services, the National Institutes of Health, and the White House Office of Science and Technology Policy. Learn more about how to write to these leaders at: http://www.righttoresearch.org/blog/NIHanniversary.shtml.
8 comment(s) on this page. Add your own comment below.
First, are we to conclude that the patient in question l languished while the author and his attending tried to scrape up $15? Second, does the author have ant idea how much many OA journals charge to be published? Third, I urge the author to pay more attention to his writing if he intends to continue this campaign. Finally, I do agree that many journal publishers make outrageous profits!!
Tim, thanks for making these points, so obvious really, but like a lot of common sense often obscured by bluster and obfuscation.
Having worked in medical writing/editing for the government and professional society journals and information contractors for several decades, I can say that one cost that is not going down is the editing and desktop publishing/formatting that you note. Increasingly, manuscripts are submitted by a large group of authors, many of whom do not write English at native speaker level. Major rounds of revision and checking back with the authors are required.All of these publishers of information try to hold costs down by paying the editorial and publications staff unconscionably small wages for our expertise in cleaning up manuscripts produced (and reviewed) by researchers who seem unable to submit even a correct reference list or figures that conform to journal size requirements. The researchers ultimately get grants, higher salaries, and better laboratories for publishing, but editorial staff contributions are not similarly recognized. Publishing online actually ADDS several layers of costs, not to mention additional deadlines that often slow up publication. Print costs increase and increase, and everyone wants color graphics these days. The cost for a single article reprint is because you are NOT subscribing to the journal so there is no guarantee of steady income for the journal, as with a full subscription. The reprints help a great deal in carryng the cost of the full issues of the journals. The real way these companies make money is the occasional request for 100 to thousands of reprints for particular articles for continuing medical education or to promote a drug or medical device. And sometimes articles can be repackaged into a textbook...which is very expensive because of the short press runs for specialty books. By the way, did you try having your library obtain the article for you through their subscription service? Ask the librarian at your institution. Many services can supply articles rapidly and at free or lesser cost. As a member of the American Medical Writers Association, I can attest that we often use such means for our own research.
From the blog post author - Thank you all for your comments!
Barry - Regarding the costs of open access to authors, there are many models of open access journals. For some the majority of costs are covered by advertising rather than the authors. For many the cost to publish is significant as you point out (for example the PLoS journals). To me this cost seems very reasonable from an author perspective, as an author you publish because you want your work to be read, thus you should be happy to pay a higher cost if it ensures a wider audience. Furthermore, the majority of medical research is grant funded often by NIH and the cost to publish articles comes out of grant funds. As the success of grant holders and their chance at having a grant renewed is based primarily on publishing results this seems like a sensible cost within a grant. Finally, I do apologize if my writing was subpar!
Heather - Thank you for your insight into editing, it's enlightening to learn a bit more about both the costs of the editing process and difficulties of the current era. I would still expect the majority of journal income results from institutional subscriptions to which the large print requests you note are an smaller addition to profits. I would also note that while a single print copy of an article is likely an expensive endeavor the cost to "reproduce" a single online copy of an article is close to zero. In my mind, open access works because OA journals rely on other sources of funding (such as higher author fees) to provide a steady income stream rather than charging article costs that are restrictively high, regardless of if the costs are due to a desire for profits or as you point out the uncertainty of income included in purchasing individual articles.
I'm quite sure your correct that editing is an often underfunded part of the process. I think this point does not negate the gigantic profit margins which journals earn, rather it suggests that any increasing costs which you mention are not only passed on to the consumer but likely padded for higher profits. Finally, to answer your question yes our attempts to access the article I reference was via our institution's subscription service which I consider top notch but still lacks many resources.
The author has written an excellent article. You have made your point and there is not much to argue about. It is like the following universal truth that you can not argue with: No truth is universal, everything has its exception. Thanks for the info.
The Internet's transformation of information access has fueled interest in reshaping what many see as a dysfunctional, high-cost system of scholarly publishing. For years, librarians alone advocated for change, until relatively recently when interest in OA and related initiatives spread to the scientific community, governmental groups, funding agencies, publishers, and the general public.