By Caitlin Rothermel, MA, MPHc

Some day, we might say it all started at the BMJ.

Beginning with the first issue of 2010, clinical research articles in the BMJ print version are limited to structured 1-page summaries. The full text of these articles are available online and are accompanied by a host of additional features including tables and figures, commentaries, blogs, videos, rapid response tools, and podcasts.

For the readers, this is an abrupt shift, but Dr Fiona Godlee, BMJ Editor, says the change process was cautious and paced. “We have known for some time that the needs of authors and readers are different. Authors want length and lots of space, while print readers are likely to read only research abstracts.” Thus, the BMJ editorial staff concluded that original research belongs online, in an open-access format, with no word-limit restrictions, and alongside extensive backup content – a publication strategy that frees up more space in the print journal for educational content, columns, and reviews.

Is the BMJ approach an anomaly, or the start of a new trend in medical publishing? Albeit an unscientific sample, we interviewed several editors and publishers, who suggest that print versions of most journals, except perhaps for certain speciality journals, will remain intact for the foreseeable future. However, there was universal agreement among those interviewed that journals are substantially expanding the amount of content provided online. According to Dr David Hughes, Managing Director of Expert Reviews in Pharmacoeconomics and Outcomes Research, “There is an increasing need to augment articles in a more interactive way – to make the terrain less flat.” At the same time, he notes that a fixed role remains for print journals, for example in underdeveloped nations.

Dr Christine Laine, a member of the Secretariat of the International Committee of Medical Journal Editors (ICMJE) and Senior Deputy Editor of the Annals of Internal Medicine, notes that the publishing world is watching closely to see if the BMJ experiment takes off. Says Laine, “This change certainly fits with the realities of practising physicians, whose biggest pressures are related to limited time, including limited time to read medical journals.” The change also reflects current ‘green concerns’ related to paper, printing, and transportation (the reduction of which, serendipitously, translates into financial savings for journals likely to be deprived of print advert revenue). Although Laine and others have found that readers still want to ‘hold the paper’ when they perform in-depth reading, they also think that e-readers like the iPad will become the next norm. According to Laine, “People tend to use print when they are sitting down reading something in-depth, and electronic information when they are looking in a more hurried manner.” In other words, we have not yet found the e-technology that will force that final step away from the printed page.

However, Hughes believes that BMJ’s ‘hybrid’ content is well-suited to its new publication plan. That said, he indicated that format might be unfavourable for other publications or article types – such as the comprehensive reviews favoured by Dr Hughes’ publication, which would not translate well in abbreviated form.

Dr Gregory Curfman, Executive Editor of the New England Journal of Medicine (NEJM) believes that rapid turnaround is one absolute benefit that online publication offers to both researchers and journals. Says Curfman, “To keep information from the health care community simply because the printing press has not yet run does not make a lot of sense to me.” However, Curfman also believes that a ‘tipping point’ has not yet been reached where researchers will be satisfied with online publication only; authors still want the sensory experience of being able to see and hold their published work.

Christopher Carswell, Editor-in-Chief of PharmacoEconomics, offers a more cautious view of fast-track publication. He is concerned that it would be impossible for editors and peer reviewers to adequately review or revise a clinical study or health economics model under extremely tight timelines. Along similar lines, Laine warns of the need for increased editorial vigilance once online content grows and word limits disappear. If journals publish articles online without sufficient editorial input, says Laine, “this will do a disservice to the readers, who really need to understand the methodological details of the study.”

Laine cites the authorship burden imposed by space limitations when dealing with complex research methodologies such as meta-analyses or systematic reviews. Carswell agrees, and emphasizes that online access enables readers to more closely review and understand the design and content of health economics models. Says Carswell, “Whether it is a standard Markov decision tree or a regression, you just cannot include that level of detail in a printed paper. This is an effort to increase transparency.” Of interest to HOC readers, Carswell also mentioned that the International Society for Pharmacoeconomics and Outcomes Research (ISPOR) has recently implemented a task force to develop standardised guidelines for health economics and outcomes research publication preparation and submission.

Excluding these caveats, however, publishing professionals agree that making more content easily available online is a positive step forward. Curfman and others note that online readership is swelling, even as print readership shrinks somewhat. The BMJ experiment is into its fourth month, and Godlee notes that, despite some concerns expressed during the transition period of the last couple of years, not a single complaint has been registered since the new format’s introduction.

What’s next for BMJ online? How about brief commentaries from authors, as well as full access to the peer reviewer-to-author communications? In addition, the BMJ editors hope to provide authors with the bandwidth required to publish all of their data online.

Although Hughes expresses some sadness that the increased computerisation of our medical literature might lead to the death of activities such as perusing the actual journals in an actual library, he is happy to acknowledge that the benefits of serendipitous browsing might extend to the online universe.

According to Laine, no matter what course is taken, the top priority for editors should remain the same. “We need to focus on publishing papers with the potential to effect change in how we care for patients, educate physicians, or set the agenda for future research.” At the same time, to hold onto and even encourage greater readership, it is imperative for publishers to try and anticipate how physicians will use information 5 to 10 years from now. Laine says, “We need to try to be more forward looking, as opposed to always playing catch-up.” If this is the case, the next few years in the medical publishing industry should definitely be interesting