The Future of Medical Publishing

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.