Friday, April 2, 2021

Medical Library Access For Everyone


Medical library access is a critical issue for physicians because only a few physicians have access to all of the literature that they need.  For as long as I have practiced medicine and psychiatry life long learning has been a stated goal of the profession.  That forms not only professional behavior but it is also incorporated into the medical practice laws of each state.  In order to be relicensed each year, medical practitioners also have to fulfill the continuing medical education (CME) requirements in each state.  That typically requires a combination of self-study and CME courses sponsored by various medical education organizations typically departments of psychiatry or professional organizations.

When I first came to the Twin Cities in 1989, I worked for a large multi-disciplinary clinic in St. Paul, MN.  We were the second largest hospital-based practice in the Twin Cities and a Level 1 Trauma Center and Burn Unit.  We had the most psychiatry beds in the East Metro area. I did a rotating internship at this hospital and liked the practice and the attendings well enough to return there and stay for the next 22 years. We also were a teaching hospital and trained medical, surgical, and psychiatric trainees from the University of Minnesota.  As a result of that position, I was expected to train resident physicians and medical students. At some point we were given electronic access to the Biomedical Library at the University of Minnesota and could access a wide array of biomedical journals online at that facility.  Up to that point, I had to go to the library and make copies of articles that I wanted to study and keep for future reference.  I was also able to access interlibrary loan articles through my hospital library that I would get via mail or fax in 2-3 days.  All of this reference material was relevant to my clinical work, teaching, and research at the hospital.

In general, University training programs depend on their affiliated or adjunct staff and facilities for teaching residents.  These affiliations result in broader clinical exposure to both patients and practitioners as well as different work environments. Good examples of the necessity of these affiliations is the amount of individual and psychotherapy supervision residents require.  Much of that training is provided by practitioners in the community who are doing the work every day.  In some cases a University training program may lack a critical component like an addiction service or a community psychiatry service and these affiliations provide those resources.  In return for the services provided to the training program, the affiliated practitioners get University titles and electronic access to the library.  In todays work environment stressing excessive productivity, there is generally no break in the work of the day.  For example, the adjunct teachers are still required to put in a full day’s work in addition to their teaching and supervisory role.  All of the work for the training program is uncompensated with the exception of the access to the library perk.

In my case, the other physicians in my group had negotiated with the University so that we all had regular Assistant Professor titles. We understood our role was critical to the components of the educational program and that these titles had nothing to do with regular track university titles.  As time went by our group was acquired by a managed care company and the teaching role diminished.  There was some turmoil at the University and a non-psychiatrist was appointed temporary department head. He ended up sending out letters firing numerous adjunct faculty – myself included.  The letter stated that we were "costing the department too much" as the rationale for the “firing”.  Since I was curious about how much I could be costing, when I had not ever been compensated – I called the University and asked them that question.  The answer was a $1,000/year library access fee. When I got that figure I called the University library and asked them if I could retain library access by paying them $1,000/year and they declined giving no good reason other than "it is policy".

To establish how much an individual physician may expend on journal resources – I include my subscriptions below.  The total cost is $2,640/year for a very inefficient way to access articles of interest.  Some are more inefficient than others. For example, my APA membership includes 1 of a possible 5 journals.  Just a few years ago it included at least an additional journal, but now the other journals are all for addition fees.  By comparison – the AMA membership includes access to 11 journals for only slightly more money.  Getting all of these journals to read only a fraction of the articles is also very inefficient.  The educational and self-improvement goals of individual physicians depend a lot on medical specialty and current practice environment as well as how much interest they have in the biology relevant to that specialty. Early in my career I was in a research position where we all got a hard copy of Current Contents, checked off the articles of interest and got the reprints within a day or two.

Another level of inefficiency is introduced at the level of publishers.  If you think about it medical publishing is a relatively low-cost endeavor.  Publishers are not paying for content. All of the submissions to their journals are generated for free by scientists and physicians wanting them published.  The peer reviewers who expend significant amounts of time reviewing these articles are not reimbursed.  The costs are basically for a small editorial staff, maintaining an information technology (IT) infrastructure and Internet presence, and printing paper journals.  Ideally, paper journals could be eliminated and readers could access the electronic copies and read and print what they want. We are not in the ideal world at this point. Many if not most publishers do not provide access to electronic only journal copies.

Licensing agreements between publishers and services that aggregate publications is also a controversial area. Publishing has become a very high margin business, particularly if that publisher has a number of widely read journals. In some of these cases, the annual licensing fees are easily in the millions of dollars per year for large university facilities.  That has led some library facilities to refuse or threaten to refuse agreements with major publishers so that their journals cannot be accessed.

Given this landscape, is there a possible solution that resolves the physicians need for eclectic reading, the state’s interest in physicians with life long education, the library’s interest in providing a useful service to its patrons, and the publisher’s interest in being paid.  I think there is and that is to make the University medical library electronic services available to anyone willing to pay an agreed upon fee. I was willing to pay $1,000/year 12 years ago and I am clearly paying much more for limited individual access to the journals listed in the table below.  Basically, the state and the library’s ability to negotiate group access will makes it more widely available to more physicians or for that matter anyone in the state who wants the equivalent access to electronic journals.

There are alternatives to paid journals for access.  Some grant recipients need to provide a free copy of their paper that is posted as open access on the National Library of Medicine web site (in their PubMed search engine). There are open access journals, many of which charge the authors a publication fee.  I was an editor for one of these journals and came away from that experience with the perspective that it adds significant conflict of interest for the publisher and may encourage the publication of low-quality research for profit. There are many high-quality journals that have added a smattering of open access papers for one reason or another. During the current pandemic many high-quality journals have offered articles relevant to the pandemic as open access. There are also research sites where authors can be contacted to request papers and pre-print servers where you can read the unedited versions. All of these indirect measures assure some level of access to articles that might be behind a paywall, but it is no guarantee.  For example, my requests to researchers are successful about 50% of the time and in many cases, they tell me they are prohibited from sharing their research due to copyright constraints.  The only way that you can review the literature for writing or research purposes is with complete access to what is out there.

At some point I am hopeful that physicians and/or their professional organizations advocate for these services.  

George Dawson, MD, DFAPA

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1 comment:

  1. Another bizarre example of how the industrial model for healthcare harms society! I had no idea that I was costing my medical school $1000/year by accessing its online articles. My school does not subscribe to a particular journal in which I published two papers and for which I have done some peer review, so I can't read that journal (no way am I going to pay out of pocket). If all physicians had free access privileges, the traffic would not increase much and the actual drain on resources would be minimal. The value of an increase in a physician's effectiveness resulting from unencumbered free access would amount to millions of dollars in some cases, certainly enough to justify an overall social benefit.