Open Access UpToDate

Yesterday I commented on how members of the University of Washington community were shocked to hear of the subscription cancellation of the UpToDate reference. Read this to get up to speed. The basic story is that UpToDate wanted to charge the UW a fee that amounts to 60% of the Health Sciences Library's budget. To that, the UW said no.

My peer group (medical students) were surprised, appalled, outraged, and saddened by the news.

I say, "eh..." Let me tell you why.

UpToDate is an extremely easy way to learn about the consensus understanding and treatments for a large number of diseases and medical conditions. Maybe it's too easy. For many years, it has been the one stop shop for clinical pearls, research and both general and specific information. The company knows this. Now is the time to cash in. For many students, it's the ONLY place they go for information. For some, it's just the first place. (Every article has extensive reference lists that lead back to the primary data.) What we (myself included) have fallen into is a reliance on an information monopoly. The funny thing is that this is a monopoly of convenience. Part of me thinks that UpToDate is within its rights to charge whatever they want for their well organized service - this is a free market, after all. The rest of me is repulsed by the price this company is charging for what amounts to information that is already in the medical literature.

So Duke, Johns Hopkins and now the University of Washington have said, "No, thanks" to a convenient tool. These aren't poor backwoods places. I have not heard much ideology behind these decisions; today our dean restated the financial motivation for canceling the subscription. Why might a few giants making this choice be good for medical education? Here are three reasons:

1. Intellectual Laziness. In a response to my article yesterday, one UW professor lamented that third year medical students no longer scoured medical literature, medicine textbooks and other information sources when researching their patients' conditions. I know that as a student, I very much appreciate the ease of using one resource for all of my inquiries. It leaves more time for patient care. BUT, UpToDate articles are authored by one or two people, and believe it or not, medicine is rarely definitive. It could be useful to know different opinions when relevant. There's a good chance that relevant professional societies (take the American Academy of Pediatrics, for example) already publish recommendations, and make them freely available. The problem is that you have to know where all of this information is. The benefit of knowing the location of all this information is that you are actually closer to the basic decisions that affect care. Here is where a web resource portal comes in handy. Health sciences libraries need portals like this one to help care providers find the information they need. UW's HealthLinks page is a good start, but in the post-UpToDate age, will need much improvement.
   
2. Conservation of Resources. I am guessing that residency programs, departments, and even medical schools may cough up the money needed for their trainees to access this resource. As I understand it, every single person with UW network access could use UpToDate. Because of the UW's size and far-reaching extent, this could be on the order of 100,000 people. The people that need the kind of rapid access to information that UpToDate offers are students and trainees who are pressed for time in the context of 80 hour work weeks. (and who are used to the convenience of a single information source). If the medical school pays for this smaller number of subscriptions, then the health sciences library can order more subscriptions to basic and applied sciences journals that researchers crave.
3. Open Access. For me, this is the elephant in the room, and one that I hinted to earlier. My premise here is that this information is not new. It's a repackaging of basic and clinical science that is already out there. I think there is a legitimate mechanism by which UpToDate-styled reviews could be published free. After all, how much do UpToDate's authors get paid? I hope it's a pretty penny given what they are charging universities. In other academic spheres, if academic publishing is a for-profit venture, it's the publishers who profit. The authors get paid in the currency of academia: peer reviewed articles. "Open access" is a system where authors subsidize the costs of making their work available so that any reader can access it. This is an important trend in academia. The ivory tower is being disassembled and reconstructed into a public works project. But wait, if UpToDate doesn't pay their authors much (this is an assumption that I have not verified), why does it cost so much? I think the company would argue that their easy to use platform is worth something, as is the verification of the information as legitimate. In basic, clinical and applied sciences, this is done through the volunteer system of peer review. I am guessing UpToDate pays people to verify the information. Even so, I do not see why this needs to be for-profit. Why not use an open access model for these review articles? Open access works for 3,314 other journals. There are very well established mechanisms for running such systems, including the Public Library of Science family of journals. I would imagine that an UpToDate-styled review could fetch the prestige among clinicians as a Nature paper does for basic sciences. If the academic currency of publishing these clinical review articles could balance their widespread utility, why inject large sums of money into the system?

In the end, I think there are good theoretical reasons for abandoning expensive subscriptions to clinical review literature. The information is already out there. With a little help from librarians, we'll be able to keep providing the quality of care that the UW, Johns Hopkins and Duke are all known for. Who knows! Maybe the system will come out better in the end.