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The “M” in STM Publishing

Caduceus yellow

The caduceus, the traditional symbol of Hermes featuring two snakes around an often winged staff, is often mistakenly used as a symbol of medicine instead of the Rod of Asclepius, especially in the United States of America. The two-snake caduceus design has ancient and consistent associations with commerce, eloquence, trickery, and negotiation. Tangential association of the caduceus with medicine has occurred through the ages, where it was sometimes associated with alchemy and wisdom. The modern use of the caduceus as a symbol of medicine became established in the United States in the late 19th and early 20th century as a result of documented mistakes, misunderstandings and confusion. (Photo credit: Wikipedia)

The “M” in STM publishing has always held a special interest for me, as medical publishing represents something of an aspirational model for research publishers.  Medical publishing finds many markets, from academic libraries to hospitals to individual practitioners.  It is also buttressed by a big chunk of advertising, something that, say, publishers in anthropology can only dream about.  And health care is 17% of the U.S. economy:  surely a market of that size will drive growth for years to come.

An excellent snapshot of the current state of medical publishing can be found in the recent report, Simba Information’s Global Medical Publishing 2013-2014, which you can purchase here. I should disclose that the lead author, Eric Newman, is a friend of mine, both of us part of the extended network that emanates from Gordon Graham, the patriarch (who was, among many, many other things, the founding editor of Logos, to which I was formerly a contributor).

There are lots of nuggets in this report, though its real strength is in the company by company profiles, which cover the entire industry segment.  I was particularly intrigued by the section on TruVen Health Analytics, which is controlled by a private equity group.  TruVen represents the medical publishing units that were spun out of the Thomson company (now Thomson Reuters).  TruVen shares with another Thomson spin-off, Cengage, a penchant for coming up with ridiculous company names.  Cengage slid into bankruptcy, so I ask:  What’s in a name?  Actually, quite a bit.  When companies have names that do not describe products or the people behind them, you know that the financiers, not the operators are in control.  One of the 10 immutable laws of publishing is that when a publisher strays from its origins in the editorial enterprise, the spark that gave rise to the company in the first place is snuffed out.  I don’t know what the other 9 are.

But the nuggets:  In 2012 medical publishers had global sales of $10.1 billion, about a third of which came from journals (the figures also include books, conferences, and newsletters).  This represents a mild decline, as the Great Recession took its toll.  Overall medical publishing has been flat for several years now.  But $10 billion is a big number, is it not?  And this is without including the non-professional areas for health care (e.g., Web MD).  But it is interesting to see that even medical publishing could not fully withstand the aftershocks of the global financial crisis.  Isn’t health care supposed to be immune (cough) from the swings in the economy?  (According to the Simba report:  “Medical publishing is not directly linked to GDP, but the size and relative growth of medical publishing does tend to follow overall economic health.”)

For my part, I am struck by how small $10 billion is.  Health care is about 17% of the U.S. economy; that’s 17% of $16.62 trillion in 2012.  The U.S. has about 25% of the world economy.  $10 billion may be a nice figure for a 27-year-old Silicon Valley entrepreneur, but as a piece of the overall economy, it is a pittance.  So one strategic question for medical publishers is how to make their products and services more integral to health care overall–how, in other words, to create more value.

Unfortunately, some of the figures are moving in the wrong direction. Medical advertising is down and, as far as I know, is showing no sign of picking up.  The reason for this is one of the unanticipated consequences of the migration from print to digital products, the fall-off in advertising.  Advertisers look at print publications and say, Isn’t all the excitement with digital?  But when they look at the digital opportunity, they see enormous inventory, which drives the price of advertising down (typically by 90%). I hope there is no one left alive who believes that advertising, outside a handful of key consumer services, is the key to monetizing online publications; it’s either user-pays or author-pays.  The secular decline of medical advertising undermines the notion that medical publishing represents a model for publishers in other domains to emulate.

Medical publishers are finding growth in new markets (e.g., Brazil, Turkey) and in mobile media.  Since medicine is a global affair, we should not be surprised that emerging economies are generating new opportunities, something that is largely true for many other STM segments.  This is yet another area where humanities publishers are more constrained, as the future role of medicine, information technology, chemistry, and physics around the world seems assured, but this is not always true for studies of literature, history, and political science.  I am anticipating increased mergers and acquisitions activity as global medical publishers pick up local publishers around the world to accelerate their penetration of these markets.

With mobile media, medical publishers probably have an opportunity that is greater than for any of its peers in the STM world.  Doctors see patients; they use mobile devices to access information quickly during an examination.  While no professional publisher nowadays can afford to ignore mobile platforms, medicine may be unique in that mobile usage potentially represents additive business as important information is brought to bear on emergency situations.  This means new investment in app development and also having to learn how to navigate the difficult business rules of some major consumer technology companies (that is, Amazon and Apple).  We should look for signs of a new mobile ecosystem arising around different platforms, as professional publishers seek greater control over their products and services.

So with medical publishing we have a situation that, however varied in some of the particulars, is essentially consonant with that of other segments.  STM publishing is mostly mature; companies have to fight for growth.  While some growth can be earned in emerging markets, overall this is a market-share battle.  Market-share battles lend themselves to consolidation.  Thus the financiers will be the key players in STM publishing during this phase.  We will be seeing more funny company names in the years ahead.

About Joseph Esposito

I am a management consultant working primarily in the world of digital media, software, and publishing. My clients include both for-profits and not-for-profits. A good deal of my activity concerns research publishing, especially when the matter at issue has to do with the migration to digital services from a print background. Prior to setting up my consulting business, I served as CEO of three companies (Encyclopaedia Britannica, Tribal Voice, and SRI Consulting), all of which I led to successful exits. Typically I work on strategy issues, advising CEOs and Boards of Directors on direction; I also have managed a number of sticky turnarounds. Among other things, I have been the recipient of grants from the Mellon, MacArthur, and Hewlett Foundations, all concerning research into new aspects of publishing.

Discussion

8 thoughts on “The “M” in STM Publishing

  1. Another great post. While I’m not spending $2,500 to see the Simba report, the report has to be based either on “medical” in the limited sense (medicine) or “medical” in the larger sense (medicine and surgery). As someone who recently shifted from publishing in the internal medicine specialties to a subspecialty of surgery (orthopaedics), the fact that there are major differences within “M” has become very clear — customers are different, how they relate to manufacturers is different, and their information habits are different. Most of the advertising drain has hit journals and publishers reliant on pharma advertising, while device advertising (which can include orthopaedics, ophthalmology, a portion of oncology, and a few others) remains fairly strong, even in print.

    One of the real problems for medical publishers is that they publish preliminary results, which makes it a real challenge for them to offer anything at the point of care. Making a reference work is a completely different way to generate content, and diverting editorial muscle to pursue something that also seems more commoditized (hence, less valuable, more difficult to differentiate, and lower margin) appears risky and expensive. For busy editors, it looks like you have to boil the ocean to make a comprehensive reference work, as well.

    Education is an area where a lot of medical publishers are seeing some room to grow. The barriers to entry can be lower, and the focus on the professional audience is strong. It is also an area that’s compatible with publishing novel results. There are increasing needs in this area, and with travel budgets shrinking and bandwidth widely available, online solutions are proliferating.

    Posted by Kent Anderson | Sep 10, 2013, 7:13 am
  2. Good post! Is there much interest in a “consumer” version of scholarly medical articles? Reviewers typically (and correctly) demand details, qualifications, and explanations that make a scholarly article difficult for the average person to read. Given the public’s interest in medical issues, I would think publishing products offering summary versions of articles might have a lot of appeal.

    Posted by Ken Lanfear | Sep 10, 2013, 10:00 am
    • I believe that’s the job of the consumer media. Most health reporters — print, radio, online — do a great job of translating scientific studies for the consumer audience. I’ve often seen editors reading the news articles to get the real gist of a study they’ve published. The clarity of the reporting, the context journalists add, and the interviews they sprinkle in can really bring the points home in a well-done piece.

      Posted by Kent Anderson | Sep 10, 2013, 11:36 am
      • True, some reporters do a great job. But why is there such a push to make government-supported medical research articles open to the general public? My fear is we are jumping into an OA environment for scholarly articles when what we really need are better explanations of the work.

        Posted by Ken Lanfear | Sep 10, 2013, 12:00 pm
  3. Consumers do already some have some very good options for obtaining quality medical info — from sites like WebMD and the Mayo Clinic which produce content written at the consumer level. In addition, health plans and numerous healthcare systems offer content licensed from publishing organizations and tailored specifically for patients. (This is all over and above the traditional pt. ed. type handouts that doctors have used for decades.) Having a consumer-version of most medical research articles would likely not serve consumers well because what they need is a synthesis of clinical state-of-the-art, not just the latest advance which may or may not apply to them. As Kent notes, many health reporters do a terrific job of translating the latest research into plain English.

    Posted by SusanG | Sep 10, 2013, 12:17 pm
  4. I have yet to read the Simba report, so apologies if I repeat directions already outlined in the report.

    I suspect that tomorrow’s medical publishers, who manage to move the market share needle, will be ones who are maybe barely recognized as medical publishers today. They may the ones who capitalize on data that medical publishers largely do not think of as medical content today. Maybe the growth of medical publishing will be about a transformation of what we perceive as medical content and publishing.

    I wonder if wearable device providers, quantified-self services, patient record holders, and companies that organize and analyze this rich personalized data/ content will become more valuable ‘medical publishers’ in the eyes of a personalized healthcare industry than today’s medical research and reference publishers?

    Maybe this is where the $10 billion needle for medical publishing will move significantly in coming years.

    Posted by Neil Christensen | Sep 10, 2013, 8:21 pm
  5. Gordon Graham advised me, at the outset of my publishing life, to get an accountancy qualification, the better to argue the case. He himself had taken a qualification mid-career and found it very useful he said.

    Medical publishing has sloppy boundaries and a range of business models.

    First, there is a textbook market for healthcare professionals dominated by Wolters Kluwer, Elsevier and the like which is not really different from any other branch of higher education publishing.

    Then there are journals, with some big stars but a lot of smaller ones, again the territory of Elsevier, Wiley and so on with big holdings in the hands of medical associations; and clusters around the big ones like BMJ and JAMA. The biggest and best read get loads of advertising and the rest don’t.

    Next is medical reference, which as noted above is very tricky as there is a lot of primary material to sift in order to offer anything useful at the point of care (and away from the patient consultation there is only a small market and references date badly if not expensively managed). The best examples of medical reference for the point of care are the British National Formulary BNF (http://bnf.org) where I used to work, and the few others of this kind (New Zealand and Australia have them). Also there are clinical reference sites such as BMJ Best Practice and UptoDate (Wolters Kluwer) as well as TruVen’s Micromedex product.

    Much money is required and clever alliances needed to bring these to the next level – decision support. Broadly this involves integrating content with transactional logic within the clinical systems used to record patient details, diagnoses, order lab tests and prescribe drugs. There are very large corporations such as McKesson, Cerner and Epic waiting for those who try; and the prospect around the corner is for the whole of evidence-based medicine to be turned on its head by the use of Big Patient Data as evidence to improve patient outcomes. Intermediate steps to this are represented by some of the apps around, including Epocrates. Only a few independents exist, of which Trip is a really good example http://www.tripdatabase.com.

    Medical education beyond initial qualification (see textbooks) is satisfied by free resources from pharma industry sponsors, sometimes disguised as independent work. There have been many concerns about this sponsorship (see, for example, the splendid diatribe Bad Pharma by Ben Goldacre) but one consequence is a stunted market for author-pays or user-pays medical education materials. Some government-sponsored efforts have been made, including those by NICE Evidence in the UK for example (http://evidence.nhs.uk) which also provides a reference source in the form of a big searchable knowledge base.

    The market for patient education materials is ancillary to the professionals above in large part. It is a rare hypochondriac who needs a comprehensive reference, but the web abounds with specific patient information and for my money the best place to look would be the patient charities as it is their mission to explain and help patients post-diagnosis. Self-diagnosis has been recognised as highly tempting but psychologically flawed since the ancient Greeks, so let’s not go there!

    I think it is easy to miss bits of the medical publishing market (like decision support for example) and it seems the Simba report doesn’t include decision support or pharma-sponsored education companies (which is reasonable, but probably more than halves the size of the medical information market). So if when looking at medical publishing you consider that there is also a quasi-publishing complex including governments, pharma, education and clinical systems providers, you can see it is a big old mess but one which is highly rewarding and important in improving patient outcomes.

    Posted by Duncan Enright | Sep 13, 2013, 4:32 am

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