Dr. Harold Varmus, head of the NIH, has stirred up considerable controversy and debate with a proposal for publishing biomedical research on the Internet.  Originally dubbed E-biomed, the proposal, which has now become PubMed Central,  is described in detail on the NIH's website.  Numerous comments from around the world are also posted there.  An editorial critique of the original project by Arnold Relman was published in the June 10, 1999 New England Journal of Medicine.

Last year, I wrote a commentary on an article about biomedical publishing and the Internet that appeared in the Journal of Intensive Care Medicine.  Because the editorial I wrote is pertinent to the E-biomed proposal and discussion, I am reproducing it here (with the publisher's permission).

Biomedical publishing and the Internet -- the message of the medium 

Jacobson, M.
Journal of Intensive Care Medicine 1998;13:153-4

Societal structures are complex, and adapt to the challenges of technology in often unexpected ways. Predicting the effects of new technologies like the Internet on existing institutions is fraught with uncertainty, particularly early in the game. This uncertainty should cause us to take such predictions with a grain of salt, but not deter us from forecasting. What better way to elaborate our hopes and beliefs than to speculate on the future?

In a thoughtful article (1), Markovitz discusses the impact of the Internet on biomedical journal publishing. He notes that traditional, print-based medical journals suffer from a number of deficiencies, particularly the high cost of production and distribution and the inefficiencies inherent in distributing medical information via the printed journal page. Furthermore, he criticizes the trade model that forms the basis of biomedical publishing: authors relinquishing copyrights to journal publishers in return for the right to be published. He argues that the Internet, in particular the World Wide Web, represents an ideal medium for rectifying the situation.

Markovitz suggests that traditional medical journal publishers should "migrate" their journals to the Internet, offering access to articles for free or at greatly reduced cost. This would allow substantial economies, since most of the production and distribution processes would be simplified or eliminated. It would speed up the time between article submission and publication. It would greatly enhance worldwide access to the biomedical literature: articles available at the click of a mouse would represent a major convenience for physicians in the developed world, whereas the reduced costs of access would allow physicians in developing countries access to articles previously unavailable to them.

Beyond migrating journals to the Web, Markovitz argues that it might be time for a paradigm shift for breaking out of the trade publishing mold.  Unlike biomedical researchers, commercial authors receive financial compensation for each copy of their work that is sold, and thus they have an interest in selling their intellectual property rights to publishers, who can restrict illegal distribution and help the authors reap the rewards of their efforts.  Medical journal authors, on the other hand, are not directly compensated for their efforts and have an interest in the widest distribution of their efforts.  Thus, according to Markovitz, the primary reason that biomedical journal authors give up their copyright interest is because they have no other way of distributing their work. With the rise of the Internet, this situation no longer holds and anyone can become a publisher. Medical journal authors, possibly in conjunction with academic institutions or other organizations, could publish their work for the broadest possible audience, without relinquishing copyright to it. The stranglehold of the journal publishers would be broken.

How does this analysis mesh with broader predictions concerning publishing and copyright on the Internet? A particularly illuminating article about the impact of the Internet on intellectual property rights was written by information expert Esther Dyson in 1995 (2). In that article she predicted that, because so much intellectual "content" will be available for free online, it will be much harder to sell content to users of the Internet. On the other hand, information will be given away for free in order to attract users who can then be targetted for advertising and marketing purposes. In Dyson's words:

We are entering a new economic environment where a new set of physical rules will govern what intellectual property means, how opportunities are created from it, who prospers, and who loses Intellectual property will be copied so easily and efficiently that much of it will be distributed for free in order to attract attention or create desire for follow-up services that can be charged for.

This general prediction has been borne out in one corner of the medical information world: medical literature searching. The MEDLINE database is a copyrighted, electronic catalog, produced and owned by the National Library of Medicine.  It has been available at substantial cost to individual users for many years. Today, the entire MEDLINE database can be searched instantaneously on the Web, for free. How has this come about? A few years ago, several "medical communications companies", sponsored primarily by the pharmaceutical industry, purchased licences to distribute MEDLINE and proceeded to offer free searching from their Websites in order to attract physician users. As a result, physicians who had access to the Internet were no longer willing to pay anything for online access to MEDLINE. Within a short time, the NLM itself made the entire database available to the public for free.

This is a prime illustration of Dyson's theory. If Dyson's views hold more generally on the medical Internet, and if the MEDLINE scenario plays out for biomedical journals, Markovitz's prediction of medical journals migrating online and offering more and more content for free or at very reduced rates is likely to come about.  Journal income lost from subscriptions will be offset by a number of revenue sources. Some income may be collected through small, per-article download fees (on the order of a few cents per article downloaded), multiplied by enormous numbers of transactions worldwide. Income from advertising and marketing will play a substantial role; these can be much more efficient and targetted on the Internet. Finally, there will remain a core of print-journal subscribers willing to pay the price of full journal subscriptions as before.  Again, the evolution of literature searching on the Internet must be viewed as an economic harbinger for other forms of medical information retrieval.

On the other hand, although Dyson predicts that ownership of content will yield to service provision, this in no way requires that publishers roll over and die; they merely need to adapt to the new information marketplace. In my opinion, Markovitz's prediction of a paradigm shift, with copyright snatched from journal publishers and returned to authors, underestimates the importance of biomedical journal publishers to the peer review process and fails to take into account their central role in the power structure of medicine.

Markovitz acknowledges the necessity of peer review, but feels that research results published on the Internet could be adequately reviewed online, without the need for powerful publishers. Peer review is a complex process that is constantly threatened by internecine rivalries as well as by an exceedingly powerful medical-industrial complex.  Although the current peer-review process is certainly flawed, it has evolved over the years and is strong enough to contend with these forces, at least most of the time. Self-published articles, whose potential lack of integrity does not jeopardize the reputation of a large publishing house, are more likely to be subverted by competitive pressures in the research community and by the pharmaceutical industry.  Confidence in online peer-review that is not backed by a longstanding reputation (deserved or not) will not be easy to come by.

But even assuming that online peer-review could be adequately implemented, those who predict the demise of the biomedical publishers (3) ignore their role in the medical power structure. Medicine is an intensely competitive and hierarchical social structure. Careers advance and decline based on publication in established medical journals. This central role of biomedical publishers in regulating the careers of the most powerful people in medicine is a major factor in the continued existence of these publishers.  It will be a long time before someone whose research is publishable in one of the major journals decides to publish it online instead.  As long as publishers of the most important journals can attract the work of the best researchers, their symbiotic relationship will maintain the status quo.

Does this mean that there is no role for independent publishing of research results online? I believe that some independent publishing is likely to occur, particularly in niche areas as well as from researchers who, for whatever reasons, are slighted by the mainstream.  These efforts are likely to augment the current publishing model, however, not to supplant it.

Although I do not believe that the trade model paradigm is likely to be shifted in the near future, the revolution brought about by instantaneous global communications will almost certainly affect medical journals much as Markovitz suggests, with benefits to all who practice medicine. The medical journal of the future will exist both in print and on-line; access to articles will be free or at nominal cost. Peer-review will remain the publisher's core service. Letters to the editor will be replaced by an on-line dialog between study authors, readers and experts, while articles themselves will become organic entities, growing as knowledge accumulates, with links to relevant sources of material elsewhere in the information space. The biomedical journal will no longer jealously guard the copyright of its content, but will become a dynamic medical information service provider for all of its consumers.



1. Markovitz B. Electronic journals: time for a new paradigm in biomedical communication.  J Intensive Care Med 1998;13:158-167 [article text]

2. Dyson E. Intellectual Value. Wired 1995;July: 136 ff

3. LaPorte RE, Marler E, Akazawa S, et al. The death of biomedical journals. Br Med J 1995;310:1387-90.

Reprinted by permission of Blackwell Science, Inc.
May not be reproduced in whole or in part without permission of the publisher.


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