By David Woods,
PhD, FCPP
(excerpted from a
speech to students at Jefferson's College of Graduate Studies.)
Commenting on the
future of anything is a mixed blessing. On the one hand, for an editorialist it
offers an irresistible combination of temptation and opportunity; on the other
hand, one is mindful of the many who have upended themselves memorably on the
banana peel of prediction.
For instance, in
1800, Thomas Malthus, a practitioner of what later became known as "the
dismal science" of economics, famously foretold of a world population
imminently to be extinguished by its inability to feed itself. Today, a senior
fellow of the Hoover Institute claims that "the entire population of the
world could be housed in the state of Texas, in single-story houses -- four
people to a house -- and with a typical yard around each home."
This assumes, of
course, that you could persuade them all to move to Texas.
In 1943, Thomas
Watson, then-chairman of IBM, stated confidently that there was a world market
for about five computers. And C.P. Scott, crusty editor of the (then
Manchester) Guardian is said to have snorted: “Television? The word’s half
Greek and half Latin: no good can possibly come of it.”
No wonder Yogi
Berra vowed that he would predict anything except the future.
Since Thomas
Wakley published the first issue of the Lancet in 1823 – as he put it “to put
an end to mystery and concealment” in the world of medicine -- the sum total of
medical knowledge has increased explosively (today there are some 25,000
biomedical journals) and the speed at which communication is achieved has been
even more dramatic. In Wakley's time, the speed of communication was no faster
than a human or a horse could carry it. Today's communication is about
two-thirds of a billion miles per hour. The good news is that that's as fast as
it can go.
Unless, of
course, Einstein was wrong.
The bad news is
that costs have no such limitations. While Wakley’s Lancet sold for sixpence,
average annual subscription prices for medical periodicals surged from $51 in
1977 to a whopping average four-digit price in many instances today. No wonder
Cornell University decided to review and
severely prune the $1.7 million a year it was paying mega- medical publisher
Elsevier for some 930 science journals.
In his book 'The
Inarticulate Society', Tom Shachtman says that Americans today watch 1,500
hours of television a year, which means about 50 days a year; or, if we
extrapolate a bit, roughly nine years by the time they reach 65 if they haven’t
expired earlier from boredom. By contrast, they spend a combined total of only
290 hours reading newspapers and magazines. Part of this decline in literacy,
says Shachtman, is the chasm between the literate-based and oral languages. He
refers to a computerized scale of comprehension skill in which a "level of
difficulty" of an article in a scientific journal, Nature, rates 58.6 units,
compared with a sample of Time magazine at 6.8 and of The National Enquirer at
minus 10.3. He then goes on to note that "knowledge derived from {print}
tends to remain more detailed, to stay with us longer, and to be more broadly
based than what we receive from television." Perhaps that's why the three
principal medical television companies have ceased to exist in the past couple
of years.
Neil Postman,
professor of communications at New York University, points out that the process
of reading encourages rationality. Postman -- surely a felicitous eponym for
the bearer of such an epistle -- says that a printed page containing a
narrative or argument that unfolds line by line encourages a more coherent view
of the world than does a slambang broadcast of quickly changing, high-impact
images.
In any event,
there's a wonderful invention known as the Box Of Organized Knowledge. It has
no electrical circuits or wires or mechanical parts, can be used anywhere, and
consists of a number of sheets of paper bound together. The symbols on each
sheet are absorbed optically and registered on the brain. This phenomenon is
known by its acronym B.O.O.K.
The Economist, in
a special report on the future of medicine, noted that doctors are finding it
hard to absorb ever more information, and that American doctors typically spend
no more than three hours a week educating themselves. And for most of them, the
report says, applying the knowledge gained from reading journals has become as
much an art as a science. The information can often be conflicting and few
doctors have any idea how to resolve such conflicts. Not that this is a new
phenomenon. More than a century ago Sir William Osler noted: "It is
astonishing with how little reading a doctor may practice medicine, but it is
not astonishing how badly he may do it."
What does this
mean for publishing? It means a whole new set of opportunities. Healthcare professionals
are avid for management information, and
customer service and legal and ethical issues are all assuming new
significance; new technologies need to be explained; information technology has
to be demystified. It’s hardly surprising that an estimated 2% of our $2.5
trillion a year healthcare system is now spent on consultants trying to figure
out, and explain, what’s happening! For medical writers the opportunities are
huge. Not only in interpreting the enormous and complex advances in medical science,
but also in exploring and clarifying the healthcare delivery issues that affect
all of us: Affordability is perhaps the main one. But also the need for
‘wiring’ healthcare; the aging population; increasingly sophisticated (and
expensive) technology; malpractice and medical error; consumer power; quality
and consistency of care; the 44 million or so uninsured Americans; the threats
posed by biologic, chemical and radiologic weapons; re- thinking the way we
train health professionals and the
continuing, nagging issue of what former Penn professor of medicine the late
Dr. Bill Kissick called “Infinite needs versus finite resources.”
So with paper
costs rising, journal advertising declining, subscription prices forcing
libraries -- and individuals -- to cut back on purchases but still to demand
the best and most current information, is the way to do it an electronic way. A
superhighway?
Well, radio
existed for 38 years before it had 50 million listeners; television took 13
years to reach that number; the Internet got there in just 4 years. Today, the
overwhelming majority of US physicians access the Internet… with medical
libraries and publishers' sites ranked highest among doctors who use the web
for professional reasons.
To be sure, the
Internet is more quirky and less linear than print. Whoever said that freedom
of the press is greatest for those who own one was unwittingly prescient.
Traditional publishing is an ex-cathedra affair, top-down, hierarchical.
Electronic publishing is essentially egalitarian. Not only that, but in the
electronic age, publishers may not be the only ones doing the publishing.
Universities may be the sleeping giants
of publishing with the World Wide Web having turned every university into a
publisher and every faculty member into an author; after all, the University's
business is knowledge creation, transmission, and management.
And incidentally,
anyone who enters chat rooms on the Internet will readily see that it's only a
matter of time before we return to grunts and hieroglyphics. In medicine, where
clarity and simplicity in communication are vital, there is a crisis. Illegible
handwriting is one thing; unintelligible speech and prose are quite another.
In sum, I see a synergistic broadcasting of
information through a variety of media… with quality and relevance and
credibility of the material being the principal factors governing the user's
choice of medium. In fact, the British medical Journal suggests an amalgam of
short print articles hitched to a more detailed version of the same thing
online. The Journal also whimsically leans on the Simpsons to illustrate
changes in medical publishing. After noting that such publishing is changing
dramatically because of many forces, the editors posit four possible futures:
In the wise (Marge) world, academics innovate and publish primarily on the web,
not in journals; publishers must publish large numbers to succeed. In the lazy
(Homer) world, publishers adapt to the electronic world and continue to publish
research. In the well-informed (Lisa) world publishers have largely disappeared
and communication takes place mainly through global electronic
conversations. And in the streetwise
(Bart) world, publishers have largely disappeared, and large organizations have
become the main purveyors of research.
As the
Association of American publishers puts it: " there are some who will
rightly conclude that the changes in medical publishing are so enormous, and
the sociological adaptability lacks so
far behind, the business of print-based publishers will continue to be robust
way into the 21st century.
