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.
At some point I am hopeful that physicians and/or their professional organizations advocate for these services.
George Dawson, MD, DFAPA
Graphic Credit - Shutterstock per their standard agreement. Click on any graphic to expand.
