September 19, 2008 Hayley Citron

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Open Medicine aims to restore editorial vitality and credibility to medical journals by cutting out pharmaceutical ads and paid subscriptions. But will this bold operation improve its chances of survival?

On a wet morning in late November, Anita Palepu, co-editor of Open Medicine (OM), tries to connect her laptop to the overhead monitor in the boardroom at the Centre for Global eHealth Innovation inside the Toronto General Hospital’s R. Fraser Elliott building. About 30 OM board members mingle around her, introduce themselves to one another and sip their coffee. Some have not met until today, despite working collaboratively—and voluntarily—on the journal since March 2007. They are medical researchers from across Canada, and many know of their peers’ work in the medical field, so they fall easily into conversation.

Palepu’s slides blink onto the screen, and the first board meeting of the new online medical journal’s existence begins. The meeting will cover the journal’s mandate, budget and peer review process, among other issues. The mood is lively; the creators of Open Medicine want nothing less than to reinvent medical publishing. There’s talk of a Facebook group targeting younger med students and professionals, a Wikipedia page, and a “Donate” button on the website. There is admiring mention of the Public Library of Science (PLoS)—an organization of editors, physicians and scientists seeking to make the world’s medical and scientific research completely public. It started publishing journals in 2003 and now has a solid reputation. PLoS gives OM members hope their journal can make it too.

Open Medicine is a not-for-profit, peer-reviewed journal hosted online by Simon Fraser University’s library system. Its idealistic editorial board has aligned itself with the global open access (OA) movement, which seeks to reach audiences in both the health care field and the general public, and provides all information free of the subscriptions, memberships and fees that accompany traditional journals. Although OA has its critics—many who stand to profit from conventional medical publications regard OA journals as highly suspect, filled with dubious information and compromised by meddling government agencies—Open Medicine’s founders are un-deterred. The journal has declared itself completely free of pharmaceutical advertising to avoid all external biases and influences.

Noble, perhaps, but without subscription fees or pharmaceutical ads, OM faces the daunting challenge of creating a new funding model to suit its mandate. And establishing a new voice of medical authority won’t be easy, especially for a journal born of controversy and dissent at the venerable 97-year-old Canadian Medical Association Journal (CMAJ).

In 2005, then–editor-in-chief Dr. John Hoey, concerned by a pattern of interference in editorial matters by publishers, assigned the job of reviewing the editorial policies of the CMAJ and the Canadian Medical Association (CMA) to fellow board member and former editor of The New England Journal of Medicine, Dr. Jerome Kassirer. In his report, he concluded that objectivity in the journal was “to an important degree illusory.” CMAJ publisher Graeme Morris eventually fired both Hoey and fellow editor Anne Marie Todkill. Several other editors—including Palepu and Stephen Choi, now co-editor of OM—also left over compromised editorial autonomy. “It was quite a devastating experience for all of us,” Palepu remembers. “We thought we could have just walked away and gone on with our lives … but upon reflection … we decided it would be irresponsible not to do anything.”

Current CMAJ editor-in-chief Dr. Paul Hébert claims the journal is in a much better state today. In 2006, the CMAJ Governance Review Panel reviewed the journal and gave 25 major recommendations that the CMA acted on quickly. And many doctors, including some on the OM board, still view the CMAJ as a credible source.

Next to print publications such as the CMAJ and The New England Journal of Medicine with long-established names and track records, and fat with advertising, OM might be perceived as less reliable. The trick to a successful first year, the editors believe, is to persuade readers to consider quality, not quantity, and credibility over popularity. OM’s articles contain strong research findings that are similar to those in closed-access journals, and written to appeal to a wide range of readers. Contributors are physicians, health researchers and students. OM tries to publish new articles every Tuesday, though some months (and weeks) see more articles than others. OM ’s media liaison, Lindsay Borthwick, says the steady stream of new material makes the journal stand out. “No delays or long waits, which makes us fairly unique because the more academic or niche the journal, the longer the wait tends to be.”

OM adheres to criteria established at the Budapest Open Access Initiative of 2002, signed initially by 16 professors, doctors and publishers from around the world, and growing ever since. Authors retain copyright and ownership of their work; content must be immediately and freely available to anyone; articles can be distributed, reused and remixed without restriction as long as the original work is attributed to the author; and, all work must be submitted to a public online archive, such as PubMed Central. While author-retained copyright means no money for publishers or the journal, it also means articles are no longer held hostage, as Choi explains, “for the purpose of creating profit.”

Attention from journalists has helped spread the word. When the mainstream media picked up a hard-hitting article on breast cancer prevention and a paper on the birth weight of newborns from different ethnic groups, the journal got more hits. Dr. Gordon Guyatt’s paper discussing the difference in the results of Canada’s healthcare system versus those in the U.S. was eventually covered by CBC Radio, The Globe and Mail, 11 local newspapers, three websites, two national and one local television show, The Canadian Press and the CanWest News Service. The website got more than 8,000 hits in mid-October after Dr. Stephen Hwang’s critique of Harper government policy-making made the news. As Dr. Miriam Shuchman, a Toronto medical journalist and psychiatrist says, “Your average non-academic reader is looking for an article they can sink their teeth into. The fact that they can read anything and read the whole thing … makes a big difference.”

The publicity and the resulting hits on the site are great, but they don’t pay the bills and it will be hard—if not impossible—to replace subscription, copyright and commercial ad fees. The editorial team has supported the journal with its own money. Palepu, who has donated close to $20,000, says, “It’s definitely a challenge to find a business model that could sustain us.” So far, OM is holding strong thanks to John Willinsky, founder of the Public Knowledge Project (PKP) that originated at the University of British Columbia, and OM ’s publisher. Six years ago the federally funded PKP developed Open Journals System, a free hosting software for scholarly journals. PKP provides technical support to more than 1,000 journals, including OM, though most are in developing countries. “The key to OA publishing is to change the whole economy: to reduce your costs by taking advantage of online open source technologies, creating a much wider readership,” says Willinsky. As subscription fees rise, libraries cut back on the journals they offer each year and, consequently, the small and exclusive group that receives access to important research becomes even smaller.

Despite the obstacles, OM ’s board members remain optimistic. In the inaugural issue, Dr. James Maskalyk explained the journal’s philosophy: “To attain their true worth, medical journals need to place the knowledge on their pages into as many capable hands as possible. Now, because of the Internet … the capacity of medical journals to disseminate knowledge has never been greater.”

Open access could literally save lives. In one case, a physician from southern Africa who was working on perinatal HIV prevention made changes to a program, based only on an abstract. With access to the rest of the text, he would have known that the study results were weakly supported and the data incomplete—and probably not applicable to his situation. Indeed, his decision to alter treatments may have actually increased HIV transmission.

Barring access to full medical reports, OA advocates argue, is like taking the instructions off a bottle of pills.

Or like a doctor giving only half a diagnosis. “Clearly, discovery doesn’t happen in a vacuum,” says Palepu, noting that innovation happens when people can build on other ideas. “It’s all incremental, this process.”

Advocates are also pushing governments to adopt OA policies so federally funded research will reach all tax-paying citizens, the people whose money finances the work. In Canada, the International Development and Research Centre was one of the first government organizations to employ such a policy, in April 2007. Michael Clarke, director of the Ottawa-based Information and Communication Technologies for Development program, sees OA as a great opportunity. “Research that is paid for out of the public purse is now accessible to the Canadian public,” says Clarke, “as it should be.”

It all sounds ethically unassailable, but the movement has powerful critics. At the Council of Science Editors’ conference last May in Austin, Texas, Palepu and deputy editor Claire Kendall were among more than 400 editors listening to the introductory speech by Michael Keller, a well-known librarian at Stanford University. Palepu couldn’t believe it when he stood up and called OA journals “bottom feeders,” saying that open access allowed governments to interfere in medical writing and to censor it.

“Am I really here?” wondered Palepu. “Did I hear him right?”

She also heard another speaker claim that trying to make journals open access was a waste of money—money that could go to curing breast cancer. He also mentioned the war in Iraq; other speakers did the same. The benefits of OA were continually dismissed as subscription-based journal editors clapped in admiration. “Sometimes I had to validate with Claire that we heard the same thing,” says Palepu. “That was really disappointing.”

Meanwhile, the U.S. Partnership for Research Integrity in Science and Medicine (PRISM) actively campaigns against OA and public access. Its website claims that government-funded open accessibility amounts to censorship and is a way of stealing authors’ property or even confiscating publishers’ investments. In short, PRISM argues that this funding will eventually lead to restrictions on what research can be done, and the government could potentially benefit from an author’s work by reusing and selling his or her articles.

“Open access per se does not require government-funded research,” Palepu argues in an email. Organizations such as the Canadian Institutes of Health Research (CIHR) fund some of the most useful health studies. A group of peers review and rank the research, then funds are allocated based on importance, merit and feasibility.

Palepu agrees with Clarke that OA allows publicly funded research to be free of the restrictively high access fees. Canada recently introduced a policy that states publicly funded study results must be published and completely accessible within six months.

Researchers at universities write most of this work, and the peers who review those grants are also from academia rather than the government. According to Palepu, numerous reports have revealed that more bias exists in studies financed by commercial sponsors. Non-commercial bodies such as the government can interfere by requesting that a research proposal include a clause stating it cannot be released without government review, but this does not occur with CIHR, the foremost funding group for health research.

The OA model is so compelling that some traditional journals are now opening up. The CMAJ’s website boasts its own OA online journal, and Hébert stresses that “we are completely open access and have been for several years now.” But Palepu is quick to point out that since the CMAJ retains copyright of authors’ work, it isn’t fully open access.

Other journals and private associations, however, are afraid for their lucrative copyright and subscription fees, and are seeking help from big-time PR flaks to counter the contagious OA movement. In January 2007, Nature magazine reported that Eric Dezenhall, CEO of Dezenhall Resources, whose clients have included former Enron chief Jeffrey Skilling, met with journals and associations to brainstorm counter-OA strategies. He suggested placing simple messages, such as, “Public access equals government censorship,” within articles and blogs in journals and on websites.

Such opposition does not threaten Palepu. “You know you’re doing something right when there’s this level of discourse coming back at you,” she says. “Rather than saying, ‘Our economic viability is threatened by this and we may need to think of other ways of doing business, and our vested interests are vulnerable now with this movement,’ they obfuscate the issue with this crap.”

The real issue, she argues, is challenging the status quo. “Publishing has gone on for hundreds of years this way and now we’re in a new age, a new technology, new networking, new information systems, and as long as the same people can make lots of money, it’s been fine.” She adds, “But now that it has become increasingly democratized, this is how you resist. Nobody likes change, especially if you’ve been on top all these years. Right?”

The OA model may have its detractors, but doctors are generally warming to the idea. “I admire the model, I am impressed by it, I’m intrigued by it,” says Shuchman. “And I’m proud of the people I know who are involved in OM for pushing it.”

Back in that hospital conference room, OM members are doing a good job of inspiring each other. “How many times have you regretted doing the right thing?” says Anne Marie Todkill, to understanding nods. Richard Smith, former editor of the BMJ, previously known as the British Medical Journal, and author of The Trouble with Medical Journals, talks feverishly of the need for OM ’s success. “You’re part of a revolutionary force,” he tells them. Closed access publishing is “a badly broken model,” he continues. “We cannot go on like this. This is not acceptable. OM has a vision … a burning platform … Open access will happen, and Open Medicine will be a very important part of that.”