Integrating the Literature with the Internet


J.F. Myles Clough, M.D., FRCSC
Kamloops, BC

In 1998 the founders of the Orthogate Project (www.orthogate.org) posted the Orthogate Project Manifesto to explain their vision. Part of it read

What is the OrthoGate Project? Quite simply, the goal of this project is to make every information resource you may need as an orthopaedic surgeon, allied healthcare provider, or patient available from a web browser. This includes access to high quality electronic orthopaedic textbooks and journals - both those that exist now in the traditional sense - and those that will undoubtedly develop to take advantage of the new capabilities introduced by this new electronic medium.

It was an enticing idea; whenever you wanted orthopaedic information, of whatever type, you could sit down at a computer anywhere in the world and with a minimum of fuss, access what you needed.

In those days, it looked as though the journals were trying to ignore the Internet and we foresaw an uphill battle to convince the orthopaedic world that all orthopaedic information, especially journal articles, should be accessible through the Internet. We should have had more faith in the power of common sense and economics. By now, the vast majority of publishers of orthopaedic journals have made their articles available on the Internet. Table 1 shows a representative sample of English Language orthopaedic journals, their websites and the access to their articles.

Table 1 Internet Access to Journal Articles

Journal
What is available
Cost of
pay per view
JBJS (British)
http://www.jbjs.org.uk/
Free Abstracts
Full Text for subscribers
Pay per view for others
$10 per article
JBJS (USA)
http://www.jbjs.org/
Free Abstracts
Full Text for subscribers and Fellows of AAOS
Pay per view for others
$15 per article
Journal of AAOS
http://www5.aaos.org/jaaos/index.cfm
Free Abstracts
Full Text for subscribers and Members of AAOS
Pay per view for others
$7 per article
Clinical Orthopaedics and Related Research
http://www.corronline.com/
Free Abstracts
Full Text for subscribers
Pay per view for others
$10 per article
Journal of Arthroplasty
www.sciencedirect.com/web-editions/journal/08835403
Full Text Free as of Jan 2004
Journal of Pediatric Orthopaedics (USA)
http://www.pedorthopaedics.com
Free Abstracts
Full Text for subscribers
Pay per view for others
Price not posted
Spine
http://www.spinejournal.com/
Free Abstracts
Full Text for subscribers
Pay per view for others
Price not posted
American Journal of Sports Medicine
http://journal.ajsm.org/
Free Abstracts
Full Text for subscribers
Pay per view for others
$5 per article
$25 for 24 hours access
Journal of Trauma
http://www.jtrauma.com/
Free Abstracts
Full Text for subscribers
Pay per view for others
$25 per article


Orthopaedic surgeons who are members of the Canadian Medical Association (CMA) also have access to some journals through the CMA (www.cma.ca).

So the battle for access is won or is it? It is easy to believe that the prices quoted in Table 1 reflect a desire to restrict access and protect the subscription base of the journal. Publishers have a lot invested in the concept of a big chunk of paper being printed and distributed several times a year. The fact that most of us dont read each issue cover to cover and indeed would prefer to pick and choose what we read, is a reality to be ignored. The academic worlds response to what is seen as greed on the part of publishers is the Open Access movement.

In economic terms, these prices do not make sense. The work of placing the article on the web has already been done to allow the subscribers access. So all income from Pay Per View is additional and can attract no costs greater than the credit card transaction fee. In this information-hungry age, one would predict that there are 200 people willing to pay $2 for a view of an article for every single person willing to pay $25. Once again, one should assume that common sense and commercial pressure will bring down the price of Pay Per View to levels which would allow us to use the Web for access to most journal articles.

Is this the integration that we believe to be so desirable? Actually, it is only the transference of the information distribution system that evolved for paper journals into the electronic domain. All the delays, the expense, and the secrecy of the paper system remain untouched, as the paper journal would still be primary and the web version secondary. The paper system has two resounding advantages; the peer review system and tradition. What might be the corresponding advantages of true integration with the electronic medium being the primary domain for publication?

  • Speed, accuracy and economy. Most manuscripts leave the author as computer files these days. To transform a word processing document to a web page is literally a one-click operation. Transcription errors in computer files are extremely rare, so transfer of information from one program to another and across the Internet is almost error-free. Using the web for publication would eliminate the time consuming and expensive stages of printing and distribution.
  • Searchability. The ability to search electronic files for particular terms ought to be an advantage. As we have seen before, searching is a skill which needs to be learned and practiced, but it is still far better than trying to search through paper documents!
  • Hypertext. A hypertext document assumes that each reader will have different interests in the information contained in the site and allows each person to take a different path through the information. In combination with the large amounts of storage space that is available for data files, one can predict a new standard of reporting on research results. Those with enough interest should be able to access the raw data, the Xrays and the outcome scores. This would facilitate meta-analysis as well as enabling colleagues to check the validity of conclusions and statistics. Hypertext presentation of research results would result in layers of presentation summary, detail and data to replace the present frequently skipped linear presentation. It would be up to the reader to decide what level of detail he or she wanted to review.
  • Feedback. It takes but a moment to hit the mailto link and send your reaction back to the author of a work of scholarship. Since the object of the whole academic exercise is to thresh out the truth from all the conflicting pieces of evidence, this type of feedback should be welcomed. The British Medical Journal (http://bmj.bmjjournals.com/), which has been open access since 1998, has a Rapid Response section after each article. Typically readers who have just read the article submit comments. While this might seem like a recipe for ill-considered superficiality or grandstanding, in reality the comments are illuminating. JBJS (US) has a similar system called Readers Roundtable but it is rarely used. I reviewed the 20 Scientific Articles published three months earlier. Two out of twenty articles attracted a single comment (and the authors reply). Orthopaedic surgeons are a contentious group, not noted for keeping their opinions to themselves. Clearly, they have not yet taken to the concept of immediate feedback on the Internet.
  • Improved Peer Review. Once our inhibitions about providing feedback are removed, the path is open for a far more broad system of peer review. The exposure of the work to the critique of the entire community of orthopaedic surgeons could provide a true review by a significant subset of peers. If this proceeded openly, with the pursuit of consensus in mind, it would be a significant supplement to the present system.
  • Updating. Electronic documents are very easy to change. If the scrutiny of others or the authors own further work suggest it, the work can be and should be expanded, modified, brought up to date. Comments and further discussion (or links to them) can be incorporated. Currently, publication is the end of the research process. If we publish electronically, it could be the start of a discussion within the research community in our field.
  • Threads. Any research project seems to raise more questions than it answers. The ongoing discussion and research effort stimulated by a piece of useful research is better considered a continuum than a single event. The concept of a thread an evolving discussion of a topic is familiar to those of us who use the Internet email lists for discussion of cases. A research thread would have the added element of ongoing research with reporting, discussion, planning and investigating all going on at the same time. Editors of the future may find themselves committed to years of managing and coordinating a thread of this nature.
  • Multicentre. It seems likely that many more research projects will be co-ordinated between centres using the Internet for communication and data gathering. Once the academic centres have worked out the best ways to do this, the path is open to include all interested orthopaedic surgeons in research. Since the results of clinical research must eventually be applied in the practices of community orthopaedic surgeons, it seems highly desirable that they/we should be involved from the beginning.


Todays battle seems to be about open access and it seems certain to be won. But once research reporting is transferred to the Internet, all these other elements will be brought to bear and can be expected to raise questions about the way in which publication of orthopaedic research happens.

  • What constitutes authorship when people other than the original authors make significant contributions?
  • Who decides to update the work?
  • How do you reward these different contributors?
  • If research effort is organised into threads how is the ordinary orthopaedic surgeon, the consumer of research information, ever going to come to conclusions and change his or her practice?


There will be no shortage of contentious issues to face as the integration of the Literature and the Internet proceeds.


Resources

List of Orthopaedic Journal Websites http://freeortho.com/journals.html

OWL list of Orthopaedic Journals
http://www.orthopaedicweblinks.com/Publications/Journals/index.html

Open access publishing takes off. BMJ Editorial http://bmj.bmjjournals.com/cgi/content/full/328/7430/1

PLoS Biology http://www.plosbiology.org/ The Public Library of Science open access Biology Journal.

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