Rip Van Winkle Illustration by NC Wyeth
Rip Van Winkle Illustration by NC Wyeth (Photo credit: Wikipedia)

I’ve been reading surveys of physicians and attending focus groups filled with physicians for more than 20 years. If there’s one clear trend, it’s that science is becoming less important in the daily lives of practicing physicians. It seems to me that they are less likely to be aspiring scientists and seem more attuned to merely surviving the daily grind — paperwork, administrative duties, and patients. They don’t even bother to posture about their academic aspirations anymore. Everyone seems to be feeling burned out and hustled.

Physicians have always struck me as the great translators of science into practice — biomedicine in action — so it’s a bit alarming to observe the persistent erosion of their identification with science.

They do still pay attention to the scientific literature, but increasingly through the smaller eyepiece of the major journal brands — the New England Journal of Medicine, JAMA, the Lancet, and maybe one major specialist journal. Beyond this, the impression one gets is that science has become unapproachable for them.

There seem to be three major reasons.

There are the receiver issues — these are the ones mentioned previously, where the receivers of the information are simply too busy, too distracted, or too weary to spend time perusing the latest science in any depth. Underneath these trends are larger trends in medicine, with primary care physicians becoming gatekeepers who mostly refer patients to specialists; specialists who have to focus intensely on their areas of expertise to maintain the quality of care demanded by insurers, so don’t have time to look beyond the specialist literature; hospital purchasing and formulary systems that further limit physician autonomy; and a general lack of incentives beyond continuing education for remaining attuned to the latest findings in the literature.

Then, there are the problems caused by the senders of information. These problems are also familiar to us — too many papers, severe filter failure, untrusted brands, and the rapid churn of the information turnstiles. We are sending too much undifferentiated material to these readers, who have less and less time and inclination to absorb it. Recently, in focus groups that went beyond physicians to include scientists from many biomedical disciplines, this problem was also apparent. In response, it seems readers are shutting out the increasing noise and limiting their world to stronger signals, which carry the stronger brands. Physicians are also looking more at synthesized information solutions (e.g., UpToDate, Medscape) as ways to get a level of science that’s been vetted as practical and close to community standards for care.

Then, there is a fulcrum issue, which is best represented by Google. That is, why read information that is pushed to you when you can Google something that’s right in front of you? There is a workflow dimension to this, certainly, but also a corrosive problem of dependence. It’s good for Google, but not great for science, which often takes reflection, immersion, and inspiration to work. It’s not just a journeyman’s game, with Google as an occasional toolbox. After all, the algorithms at Google may or may not be robust enough to give physicians the best answers.

Perhaps it’s merely a coincidence, but three trends have occurred coincident with the bifurcation of physician practice and physician science, at least as I hypothesize it:

  • open access (OA) and its emphasis on the article economy
  • the replacement of personal subscriptions with institutional access
  • the disappearance of print

Each of these has contributed to an overall gestalt — science has become abstracted away from practitioners. It has disappeared from the tangible world as journals have disappeared from tables, desks, and waiting rooms. It now lives in the cloud, where it is unmanageable except through search engines, maybe. It has disappeared from professional economies, as library budgets have superseded department, group, or individual spending. And it has become a producer-side commodity, something less helpful to readers even as it has become more tractable for authors.

It’s fascinating to watch physicians talk about how science is less and less important to their daily lives. This is going on while we constantly debate how to publish more science. After all, more papers without a paywall after publication should increase interest in science, right?

We tend to forget that water can be fatal in too high a dose. There is “too much” of anything.

We’re so fixated on citations, OA, APCs, embargoes, and all the other ephemera we debate too long and too often that it’s easy to forget the purpose. It’s not to strut our stuff, it’s not show how morally superior one faction is against another, and it’s not to win some sort of Pyrrhic intramural victory. We have readers, and while it’s convenient and even easier to serve authors, ultimately we serve readers. Even our authors agree on that fact.

Reaching readers is not a passive act, with the only requirement turning the “access” switch to “on.” After all, everything has been accessible for a long time — it only required an economic exchange at the point of sale, rather than at the point of production. The notion of a point of sale may be crucial, as it kept the customer in sight.

It’s actually quite a bit more difficult these days to be a reader. There are fewer sources of continuity, more competing flashes and fewer steady beams. It’s no wonder physicians are retreating from the action into trusted brands that provide them with steady and reliable editorial experiences.

Reader-friendly innovations also seem to be slowing down as the bigger and better-funded publishing companies begin to orient themselves toward OA, which provides a source of ready money with little upfront capital expenditure or need to build a sufficient reading audience. Why pursue the longer game of creating value for readers when you can pursue a lower-cost, quick-return game with OA?

Focusing on peer-review purely as a type of validation rather than as an activity that also helps determine importance and relevance is another shift away from readers. Not only does the review itself likely suffer from some basic problem (if you don’t know who you’re reviewing for, how can you review a work properly?), but the output is not tailored for an increasingly specialized scientific community, making it both harder to find but also less likely to be picked up and used.

I’ve been criticized in the past for asserting that making something available online doesn’t mean it matters, especially to the average taxpayer — most of what is published in scientific papers is orders of magnitude more complicated and nuanced than material most taxpayers can understand, nevermind implement. Reading levels are wrong, for a starter, but even scientists in one discipline can’t understand much of the science in another, so the problem of utility and relevance is complex. Ellen Collins, a social researcher, recently wrote about the limits of utility in public access in a charming blog post after having her science discussed in the Guardian:

. . . just because we make something open doesn’t mean people will actually read it. . . . I believe in open access. I think it is a good thing that the general public should be able to see the results of scientific research. But I think we also need to acknowledge that making this complicated, messy, highly technical content open to people who don’t have the expertise — or perhaps even the inclination — to explore it properly, is a risk. And that if we are serious about openness we need to do more to help people find, read, understand and critique the original research outputs.

Jeff Bezos, in an essay announcing his acquisition of the Washington Post, hit on some of these themes, informed by his ferocious focus on the customer:

Our touchstone will be readers, understanding what they care about – government, local leaders, restaurant openings, scout troops, businesses, charities, governors, sports – and working backwards from there.

From Amazon to Apple to Google to Virgin to Flipboard, the reasons to pay attention to the actual consumer are legion. But the disciplines to be this customer-centric are often a bit alien to publishers, from reader surveys to focus groups to usability studies to observational studies to interviews. Many publishers work hard on author surveys, but little on reader surveys, or have library advisory boards but no reader advisory boards.

As we ourselves orient further back toward the producers, the customer becomes secondary. We devote far more of our bandwidth these days to serving authors, funders, and librarians than serving readers. Yes, reading is just a mode and not a person, but it’s the mode that matters the most, perhaps. Authors, funders, and librarians serve readers — we should all be aligned on this. But the move toward OA seems to be silvering the glass rather than making it clearer. We’re ending up looking at ourselves more than we are looking out for our customers.

We’re here to put science in the hands of people who can use it. This is not accomplished by the passive approach of “access.” It requires active marketing, delivery, and brand-building. Unfortunately, from what I’ve seen over the past two decades, we are losing track of the actual customers — the readers, the users, the physicians, the scientists.

If we sever that connection — based on utility, value, and meaning — we’ll certainly have lost everything.

Kent Anderson

Kent Anderson

Kent Anderson is the CEO of RedLink and RedLink Network, a past-President of SSP, and the founder of the Scholarly Kitchen. He has worked as Publisher at AAAS/Science, CEO/Publisher of JBJS, Inc., a publishing executive at the Massachusetts Medical Society, Publishing Director of the New England Journal of Medicine, and Director of Medical Journals at the American Academy of Pediatrics. Opinions on social media or blogs are his own.


22 Thoughts on "Have We Forgotten Readers in Our Worries Over Access?"

The publisher of a journal involved in a major fraud case argues against OA, the best medicine against research fraud. Curious.

Note that this commentator has not provided a real name, and did not provide us with a real email address, yet is asserting the importance of transparency and accountability.

Those ironies aside, OA provides no inherent protections against fraud. In fact, studies have shown it seems to have a pro-industry bias, and there are OA publishers who court industry papers and sponsorships of APCs. Swift action in response to demonstrated fraud is how to protect readers. Retraction and other penalties are tools any strong editorial group and publisher will not hesitate to employ in these rare instances.

I have observed that scholarly open-access publishing has actually increased the occurrence and persistence of fraud in scholarly communication.

Thank you for another insightful installment. I published traditional MEDLINE indexed cardiovascular review journals from 2001-2008 for a small publisher. Every so often we would publish roundtable discussions in a conversational format (not written summaries) held among expert physicians.

Upon review of downloads and page visits, we began noticing that these discussions were often in the top 10% of information sought by our readers – mostly practicing cardiologists. Using readership surveys and focus groups we inquired further about reader preferences for roundtable discussions. The feedback can be encapsulated as: “its easy to read, and I feel like I can learn something valuable while I eat my lunch.”

Since the launch of our current publications, I have received this message many times over from physicians – one went so far as to call me to say “thank you” when she received her first issue – she reads so she can “test her knowledge” against the experts.

I mention this not to plug our work or imply that somehow we are better than the traditional literature. What we do is opinion based, adding experience to the evidence, which is very different from evidenced based publications. We have a place in the continuum of knowledge because readers want it. I simply want to buttress your point that readability resulting in transfer of knowledge from “bench to bedside” is critical in changing practice and improving patient care, particularly in a format that will, in fact, be read.

PERQ/HCI and Kantar Media have run surveys over the past 10-15 years that ask what physicians consider to be “Important Sources of Information” – inevitably, the top three are typically, Journals, CME and their “Peers.”

As Malcolm X said on October 10, 1963 in his Message to Grassroots:

“We want to have just an off-the-cuff chat between you and me — us. We want to talk right down to earth in a language that everybody here can easily understand.”

I have read with much interest the work of the “Scholarly Kitchen Mafia,” and appreciate all of your analysis, critiques and investigations. While I don’t understand some of the subtle nuances, I certainly am learning quite a bit from the collective experience and wisdom of the SKM.

I have always been impressed by the dedication of practicing physicians to discovering news useful in their fields. As research has consistently doubled input and output, the quantity of such news far exceeds their capacity to read and digest it — even if they were to stop seeing patients.

As Garvey pointed out (1979) the individual increasingly (A) specializes (B) teams up with others (C) crosses disciplinary boundaries (D) but still unwittingly repeats investigations done by others. Review articles and online indexes/abstracts provide links to original research, but attendance at meetings and continuing education seminars are more timely.

One solution routinely overlooked in the communications debate is the medical newspaper, for example Medical Tribune in the past and lately Publishing snobs may sneer, but doctors read them.

Another is the missionary army of “detail men” (including many women) deployed by big pharma and device manufacturers to push their products. Doctors listen and ask questions, even if they don’t jump on this or that new bandwagon.

AM News, the newspaper of the AMA founded in 1958 and revamped in 2001, circulated to 230,000 HCPs and supported entirely from advertising and classifieds, is closing its doors Sept. 9 – more of the removal of print from the landscape, but not for lack of readership, for lack of advertising budgets supporting physician education – DTC television advertising is expensive.

Incredibly timely and important piece. Thank you for this. Gives us much to consider.

Yes, open access is a necessary but insufficient condition for adapting scholarly communication to the digital age. Thanks for touching on many of the other factors that will bring us to greater sufficiency once we get a better handle on them. However, I continue to suspect that the revenue-driven institutions and organizations inherited from the print era are not up to the task, if only for scalar reasons.
That’s not to say that there isn’t any ancient wisdom to draw upon. For example, the classic formula for any kind of communication:

o Know and understand your audience
o Know and understand your message
o Know and understand the tools at hand

… seems as appropriate now as it ever was.

Our editors have commented that in the 1970s and 1980s it was possible to know “everything”, and keep up by reading a couple of journals.

With the sub, and sub-sub specialization of both medicine and research, and to an extent journals, it is impossible for a practitioner to keep up with anything aside from the patients directly in front of them.

Research reports are also getting harder and harder to read. Each specialty has it’s own terminology (call it jargon if you will) and people outside the specialty are unfamiliar. Never mind the general public who doesn’t speak the language of science.

Medical journals’ goals, in the end, should be the improvement of patient care. Communicating items that should change patient care is getting harder and harder with no great solution in sight. I certainly have no answers. Except that we need to communicate the amount of information a physician wants in the way they want to receive it. And doesn’t that sound simple?

It seems to me that publishers do not know who their audience is nor what they want. Editors do not have travel budgets except for meetings.

I remember saying to my executive editor that I wanted to go on the road for about 2 weeks and call on some schools. She asked why and did I have appointments? I said no I didn’t, but that I felt I needed to get the pulse of those for whom I was publishing and learn what was needed. She commented that times have changed and that e mail is all that is needed to seek a book or start a journal.

It was then I realized that publishers had devolved into being providers of a commodity, and that Mr. McGraw’s admonition of good editors wear out the soles of their shoes and not the seat’s of their pants was no longer a way of doing business.

You highlight three trends that are all interrelated. But I think you leave out a key trend tied to these three that is, likely, the strongest contributor to practitioners focusing more on leading brands. It isn’t open access and its emphasis on the article economy that drives this change so much as the tremendous growth in the number of papers produced and available. After all, open access promotes availability once you’ve identified an important paper. It’s identifying what’s important amongst the flood that’s become harder.

And, again, these are all interrelated as the move to digital facilitated both open access and the increase in publications.

This whole discusion has a “fall from grace” aspect that is questionable. The diffusion of scientific knowledge has improved, possibly greatly. It has certainly become more complex in the process but that is actually its strength. The role of journals has thus become more complex as well.

The role of journals has become more complex, but our approach has become more simple-minded. Review for validation only (as if that’s entirely reliable) and publish it. Don’t filter, interpret, prioritize, etc. The problem isn’t with scientific information per se, but with our handling of it. We’ve become so producer-focused that we’re risking turning the entire thing upside down.

Most journals do a lot of filtering and prioritizing, plus editing, and review journals do a lot of interpreting, so I do not see what you are claiming.

Currently, but the emerging ecosystem downplays filtering and prioritizing, and review journals are a real blind spot. I’m trying to look ahead.

Kent: What do you mean by review journals are a real blind spot.


I personally detest this faddish use of the term “ecosystem” as there is nothing “eco” about the system of scientific communication, nor other advanced systems of human behavior. Or is it an emerging swamp perhaps? Or a barren ground? In any case I do not see it emerging.

Thank you for this post. I think the main problem today is that it’s just too much out there and publishers are just trying to push more and more content at us, that we, the scientists, don’t necessarily have time to consume and thus we often fall behind. I think it’s sad and dangerous the physicians are not staying current enough and it can become a real problem and severely affect the quality of care patients get. Having the end-user in mind, I started Scizzle a couple of months ago, We are still in our infancy, but our goal is to help researchers, physicians and anyone interested in science stay up-to-date and current with everything that matters to them in science.

Nobody is pushing anything; there just happen to be several million scientists working today so we get over a million articles a year, plus probably as many reports, conference presentations, data sets, etc. Thus there is no such thing as keeping up with the field if that means knowing about every research result, nor has there been for at least 100 years. Note that the general practitioner physician’s field is all of medicine so the idea that they can know everything going on is simply preposterous.

Moreover, in any field the time from original discovery to widespread application is typically about 30 years, involving a lot of different people and transitions. Thus there seems to be an incredibly over-simplified model of the diffusion of scientific knowledge in play here. Reading journals is just a small part of a very complex system.

But by the same token it is far easier to find specific work results than at any other time in history and journals have been a major contributor to this revolution in discoverability.

I was not trying to imply that one should know everything, I just said it’s very hard to keep up with the wealth of information and that there must be a better way. I believe well read scientists are better scientists, because knowing what’s going on in your field and in general is what can lead to the next great breakthrough or advance.

Admin, it is not a question of knowing everything. It is simply that one cannot read all the papers in even a very small field, because they exceed the time available for reading. In decision theory this is sometimes called “bounded rationality” but I prefer the term bounded attention. The most one can hope for is knowing the most important things going on in a few relatively narrow areas of interest. Often this means just reading headlines.

As for better ways of knowing the most important stuff, these are being developed all the time. I have developed some myself. Scizzle may be another.

David:Thank you! I think you have brought perspective to not only the discussion but also to the reality of the situation when it comes to “keeping up.”

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