Open Access
by Ellen Lewis, Ph.D.

I admit I was mildly put off when I read the first email from Atif. He had written to the "Ask the Experts" segment of RadiologyWeb and asked if I could find articles for him on the role of HRCT in chronic diffuse lung disease in patients with unremarkable chest radiographs. I sent a quick email reply suggesting that he consult PubMed and mentioning that I do not have time to do other people’s research (well, that is not entirely true, I spent two hours online last week for my son trying to find a kid-friendly website with information about the construction of bongo drums).

Atif replied quickly that he was familiar with PubMed, but that he needed full text articles, not abstracts. He was particularly interested in a recent article from European Radiology, a review of the classic HRCT features of diffuse interstitial lung diseases. "It was tailor-made for my needs," he wrote. And then, "I would be really grateful as I am stuck here."

I did not know where he was writing from—but I did know something about hunting for and finding the perfect article. And a recent review article, complete with a thorough listing of both classical and current references, is always a joyful addition to one’s filing cabinet. I was anxious to be a good Internet samaritan and I was happy to get him a copy of the article. Plus, I wanted to know more about the kinds of limitations that would lead him to send this heartfelt request to a stranger, albeit a radiology colleague of sorts, on the Internet.

In my next note to Atif I told him that I would try to get a photocopy of the article he needed and, further, that I was interested in writing a short article for RadiologyWeb about his frustrating attempts to find papers to read for his dissertation. I believe that the damage done by restricting access to medical journals has been underestimated and that his situation is an example of the subtle impedition of research and personal growth that results from exclusivity in medical publishing. Would he be willing to answer some questions for me?

Atif was gracious and generous with his answers. He is a fourth year resident in radiology at a large hospital near the capitol of Pakistan. The hospital has had a CT scanner since 1982 and an HRCT scanner was purchased early this year. They do not have an MRI. Atif told me that there are only ten MRI’s in all of Pakistan, and emphasized that his is a nation of 140 million people.

As part of his training, Atif is required to write a medical dissertation. Ostensibly it is a 200 page document on any topic which should include a review of 50 to 100 cases, an overview of the literature on the chosen subject, and a presentation of conclusions reached as a result of these analyses and his own patients. However, there are other directives for this assignment that are not immediately apparent. The residents restrict themselves to dissertation topics that were in vogue ten years ago. It is considered "silly" among the residents to choose a topic that concerns the latest intellectual advances in radiological interpretation.

These policies are the direct result of painfully hindered access to medical journals and books. The residents, aware of the enormous limitations they face when trying to research a current topic, have learned to survive by going back to the literature of the early 1990’s. In fact, Atif told me that residents often look over the foreign journals in the library first, and then pick their dissertation topic based on availability of information.

Atif’s decision to research the HRCT characteristics of diffuse interstitial lung disease was brazen. He told me that lung biopsies are often used to confirm these diagnoses and few lung biopsies are done at his hospital. Furthermore, difficult cases are usually discussed with seniors in the hospital, but imaging studies with the new HRCT scanner may not be familiar territory for the seniors. Finally, there are no books on HRCT in the library. In fact, the library receives only two or three medical books each year. I asked Atif for the latest radiology books purchased by the library and his response was, "I will get you the details about the radiology book." Not so terrible, you are thinking. They can use journals instead. Granted, the library at the post graduate institute that oversees Atif’s program gets a few local journals, including a newsletter from the Radiological Society of Pakistan, and one "foreign" radiology journal. It is AJR. Each medical specialty is limited to one journal. One. I know for a fact that most of our readership (certainly in the United States) can barely imagine this.

On the other hand, it is not difficult to imagine how different this story would be if major medical journals agreed to make older content available online in full text format. For those of you who may not be aware, border skirmishes are being fought on many fronts in scientific publishing. Medical/science journals are clinging to the notion that they have the right to control their content by offering archived articles and current issues to paying customers only. Researchers argue that they provide the journals with content for free and should therefore have some say over distribution of data that they report. Real libraries worry that virtual libraries will make them obsolete. Virtual libraries and research database services such as PubMed struggle with lack of cooperation from nervous journal publishers and the problems circle back around.

Here is an interesting fact for those of you (like myself) who think of PubMed as essential to life. The creators of PubMed, the National Center for Biotechnology Information at the NIH, have tried to develop a full text research article database called PubMed Central. Less than ten of the hundreds of medical/science journals have agreed to make older issues (usually six months to one year old) available to such a service.

The battle for open access to full text articles has an ally in a group of scientists who formed a collective known as the Public Library of Science. Frustrated by the situation with the medical/science journals, initiators of the Public Library of Science wrote a petition to demonstrate support for scientific publishers who would agree to make their older articles available in full text format to online archives for free. As of June, the petition has been signed by over 24 thousand scientists and physicians in 164 countries. The petition and more information from the Public Library of Science can by found at www.publiclibraryofscience.org. I did not check, but word has it that several Nobel laureates are among the signers.

At the end of May, the highly prestigious New England Journal of Medicine announced that it was launching a newly designed website and a new publishing policy. In their words, "Beginning six months after publication, the full text of all Original articles and Special articles will be available online for free." The policy applies to articles published since 1993. This is not exactly what the Public Library of Science asked for (they requested that the journals make all the articles available to a centralized archive resource), however, it is a gratifying step in the right direction and a compromise that more journals will hopefully adopt. If the major journals would agree to open access for articles published six months earlier, even if the access is within the website of the journal, then all that is needed is a centralized search engine with links to the individual journal sites. And a modicum of cooperation from the journals in allowing their websites to be searched.

Here is what I want (in addition to full text access for science journals which would be an invaluable aid to us medical writers): I want Atif to write his dissertation on a topic that fascinates him and serves his patients. Now that the Internet has created this unprecedented opportunity, why not make sure that the bright young residents of the world are thinking for the future rather than reworking the past?