Publishing podcast

Patrick:

Welcome back to Behind the Knife. This is Patrick Georgioff, trauma surgeon at Duke University, and I'm joined by co host Dr. Ayman Ali, who is a Duke general surgery resident and surgical education fellow here at Duke. Behind the knife. And today we're going to discuss a topic that impacts all of us.

Patrick: And that is the medical publishing industry. Now, who better to set the stage than the great medical parody artist, Dr. Glockham Feckin.

Patrick: Hey man, how's it going? Oh, great. I just had a paper published. Dude. Congrats. That's awesome. It was in a pretty prestigious journal too. Oh, wow. They probably pay you pretty well for that. Yeah. Wait, what? The journal, they published your paper. Must have paid you pretty well for it, right? Oh, well, no. The journal doesn't pay you any money.

Patrick: Yeah, but they're using your paper. Yeah, so? Well, like, if you spent years writing a book, you sell the book, you get money for it. Oh, well, I do get paid to do the

research. You know, I get grant funding. Oh, so the journal that publishes your paper, they give you grant money to actually do the research. No, the grant money comes from the government.

Patrick: So the journal doesn't pay for the research or the content that they're publishing. Are they some kind of nonprofit? Oh no. The largest academic publishing companies make like 20 billion a year. Really? Yeah, their profit margins are like 40%, which is higher than Google.

Patrick: So why don't they pay you to publish your paper? Well, I get something much more valuable than money. What?

Patrick: Prestige. Well, why can't you have both?

Patrick: Because it's not about the money. All right. So we all know that it is, of course, not all

about the money. However, the very wacky nature of this whole business model really makes you wonder how did we get here? And so to help us understand that,, I'm and I are pleased to welcome a very esteemed guest to behind the knife.

Patrick: Dr. Alan Deskey. So Dr. Deskey is a professor of medicine at the University of Toronto. He's former physician in chief at Mount Sinai Hospital and former head of the division of internal medicine at the University of Toronto. Dr. Detsky received his B. S. from the Massachusetts Institute of Technology, his M.

Patrick: D. from Harvard School of Medicine, and his Ph. D. in economics from M. I. T. He has published over 300 papers, commentaries, and editorials in leading medical journals, and has served on the editorial board of the New England Journal of Medicine, and has acted as a contributing writer for the Journal of the American Medical Association.

Patrick: And now, get this is the coolest part, Dr. Detsky has also received two Tony nominations as a producer for Jesus Christ Superstar and Come From Away. In 2023, Dr. Detsky published an article that was titled, The Changing Medical

Publishing Industry, Economics, Expansion, and Equity in the Journal of General Internal Medicine.

Patrick: So he is quite well versed on this whole topic from each side of it Dr. Desi, welcome. We are pleased to have you. Thank you, Patrick. And I'm in nuts. I'm pleased to be here. So the landscape of medical publishing has undergone significant changes really over the last decade or two.

Patrick: And as the open access model has grown, the pay to publish model has helped large publishers maintain profit margins that are similar to that of Google, Apple, And the most unusual aspect of all of this in terms of the business model is how the whole scheme really works. And in the current model, the people who provide both the content and do the external peer review receive no direct payments from the publisher.

Patrick: The publishers, of course, generate revenue from this content. And the crazy thing is the funding agencies like the universities and research institutes those who actually pay the salaries of the investigators, they need to spend millions annually to buy

back access to the work that they supported.

Patrick: Now this is not to say that journals even digital only ones do not provide important services. That are costly and they are largely related to labor costs associated with submission and editing and even production processing. With that said, the model is still truly bizarre and somewhat without comparison. Let's try to understand better how this all came to be. So Dr. Detsky, can you start us off here by talking about the history of the medical publishing industry

Patrick: sure. I'd be happy to do so. So the history of the modern publishing industry particularly in science began in the 1950s and was started by a man named Robert Maxwell, who coincidentally is Giseland Maxwell's father. And he was a very shrewd and successful business person, entrepreneur in England.

Patrick: And he began something called Pergamon Press. And those companies took

advantage of the market situation at that time where there was a strong desire for promotion and development of science after World War II. And so it was very much in the interest of governments, particularly the U. S. government of universities and of the scientists themselves to develop and disseminate their science through publication.

Patrick: And so these Publishing companies were able to charge subscription fees, not only to the individuals who subscribe themselves, but also to the universities who were eager to buy them and government was eager to fund them because disseminated dissemination and communication of research. Was the key towards technical progress.

Patrick: And so you might think that as more journals came online, there would be competition and the price would lower. But in fact, it went the opposite direction. The more journals that came on, the higher the prices

got because scientists and universities couldn't. Just choose between journals. They had to subscribe to all of them.

Patrick: So that model went on for quite a long time where individuals in science and institutions paid for subscriptions and the medical publishing industry had also the advantage of advertising in those days. Printed copies were disseminated by drug companies as one of the best advertising techniques possible.

Patrick: And so they also curated a large revenue from drug companies in terms of advertising. But that all was disrupted by the thing that disrupted everyone, which was called the Internet, which converted the industry from a primarily print a version of dissemination to a primarily digital version of dissemination.

Patrick: And drug companies no longer could use preprints or actual copies of journals

to do advertising. Advertising was more targeted through the digital media. Which you might think would have been more efficient, but was in fact much less lucrative. And so, the that coupled with direct to consumer advertising really cut the legs on, out of the out from under the tenant that was holding up revenue streams for journals, which was advertising.

Patrick: The next disruptor was the requirement for open access. So that Major funding agencies would dictate that if you're going to accept a grant and publish your research has to be available to everyone. So, journals were then being forced to have open access and the business model for open access was to shift the cost away from the publisher.

Patrick: and actually on to the writers, the authors themselves. So the parity gets even worse. Not only did they not pay for the content, but you had to pay for the dissemination

yourself. The article processing fees started out modestly at a couple hundred dollars. They've moved up to a thousand, to two thousand dollars or three thousand dollars for a low level journal.

Patrick: But top journals in science can now charge more than 10, 000 for an article processing fee because the market will bear it. The reason that scientists want to publish in these journals and are eager to pay those fees is because that's the currency by which their success is measured. Their own institutions look at the end of every year at an annual activity report, like we do in my institution, and ask, how many home runs did you have in publication?

Patrick: How many New England Journal papers? How many JAMA papers? How many Lancet papers? How many BMJ papers? How many science papers? How many nature papers? And how many cell papers? Those would be the key journals. I think I've captured most of them in biomedical research. And so, authors will Or basically pay anything to get their papers

published there.

Patrick: And what has followed along is a large number of open access journals, which can charge not as much as that, but can charge fees to keep themselves afloat. Now, let me just say one thing. The science publishing industry is very lucrative and has high profit margins, but that doesn't mean that each journal is profitable at the margin.

Patrick: So, a journal that belongs to a small society, some specialty society in surgery or medicine or psychiatry and radiology might have a limited audience, and they're profit margins might be much smaller, and that's why they need to charge article processing fees in order to keep afloat. And the large conglomerate companies like Elsevier and Springer and they purchase these journals, but they convert them very rapidly into journals that have far more publications, and they increase their

article processing charges.

Patrick: Something that I recently learned was just the scale of what you're talking about. That wasn't immediately obvious to me. You were talking about just how much open access there is now, but I learned that in 2002 there were 22 journals and in 2021 there's 17,000.

Patrick: And that I think is shocking to me. I was wondering, what do you think, is going to be in the future of this open access model and is there a problem with just the scale? So, that brings up several points. First of all, the open access coupled with Article Processing Charges, APCs brings up an equity issue.

Patrick: On the one hand, it is Equity increasing because scientists and consumers around the world will not have to go behind firewalls, pay firewalls to have access to published research. So that is an equity improving or equity increasing phenomenon. The equity decreasing

phenomenon is. That if you're a scientist in a country that doesn't have a lot of resources or in an institution that doesn't have a lot of resources or you could be Eamon Alley, Duke surgery resident, publishing a paper that needs to pay article processing charges at Duke.

Patrick: And they may think of you as because there's wealth all around you. I understand Duke's pretty fancy place. I visited there once, but you don't, you're a beginning investigator. So you don't actually have the 3, 000 to scrape together and you have to get your senior investigators or mentors to come up with the money or departments.

Patrick: Now, in some cases, Universities make deals with journals. And so what they will do is not only when they buy the subscription for the journal, they also buy the article processing charges either at zero rate or reduced rate for anybody that's affiliated with their institutions. But if you're not part of that, if you're just a scientist who discovers like the Australian

men who discovered the cause of ulcers was helicobacter.

Patrick: I'll bet they were too, like, mom and pop show Gafford Rauch, I don't know this for sure, and they might not have had any institutional resources to, to pay for it. It's quite a quaint story if you know that story of the discovery of the infectious cause of ulcers. So, this. Is the equity, the negative equity effects of open access and article processing charges, and it's certainly one that has to be addressed.

Patrick: Now, to be fair, journals do have mechanisms for you to apply to have those fees waived, Which goes back to like, that's almost my freshman economics class, microeconomics class. That's called being a perfectly discriminating monopolist. You charge the high fees to people who can afford them, and you charge lower fees to people who are willing to pay less.

Patrick: And you just scale it down all the way along and connect, collect all of the monopoly rents. That's a classic economic non competitive market. And that's what this

market is like. So those are the that's the impact of on equity of article processing charges and open access. The other aspect that you have alluded to is there really all that's.

Patrick: There's this much science out there that deserves to be published, like if there used to be 200 journals and now there's 200, 000 journals,, isn't there diminishing returns to all these people, like, are all these people actually producing valid and internally and externally valid research findings that we can adopt and improve health care?

Patrick: And that's actually not known. But one of the fears is that by having so many journals that the consumers of those journals will be unable to distinguish valid research from invalid research. And even fraud, because we do know that exists in research. There's a long story. History, sordid history of fraudulent research being published, and research that's just

simply wrong the, not intentionally fraudulent but mistaken because of bias and all kinds of other and the play of chance.

Patrick: So, there is concern that having so much published is going to dilute the nature of the science that's another area that's concerned. I'm not so worried about that. I think that the market sorts itself out and people, like, I'll use my own career. I've published maybe 300, 350 papers and I've had a lot of papers in high profile journals.

Patrick: I've been very blessed or lucky to have a lot of papers in high profile journals. But I've also had papers in low profile journals. And some of my most, the ones that I think are my most influential research papers were not published in the New England Journal or JAMA. They were published in the Journal of General Internal Medicine, for example, a cardiac risk index project that I did when I first came to Toronto.

Patrick: And some of my favorite narrative medicine stories got published in the Journal of Hospital Medicine. So you don't always get your best work in the best

journals. That's not how it works. So those, I think, are the concerns about the growing numbers of journals. Yeah, to stick with that, you had mentioned that you're not worried about it.

Patrick: That the market per se will, will sort itself out. But as we talked about at the top of the show, this, it really isn't a normal market in any way, shape or form based on the model that we have. are you worried that volume just begets volume, begets money.

Patrick: And this is a vicious cycle that the numbers will keep going up, up and up. And everyone want to get into the game or is there some break point

Patrick: I don't worry about that. Whether I'd call it appropriate or not. Appropriate is. Not even, it's not the paradigm that I would use to talk about this. Although I have to say that I have two co authors on that paper, Christopher Booth, who came up with the idea to do this. I think he came up with the idea because He was, he's a medical oncologist at Queen's, a highly successful investigator who is now moving moving forward with something called common

sense oncology, which is to get people to understand the real benefits of oncology therapies.

Patrick: And he's very smart. Was my student when he was a second year student, he came to do an elective with me and he got pissed off because he sent an article into a journal that he used to support a sort of local medical oncology journal that used to be kind of a quaint place that everybody supported just because it was part of the community and they had been bought out by, it's one of the stories we tell in our in our paper and they'd been bought out by a conglomerate who We then turned around and instead of publishing, I'll make up the number, 100 papers a year, publish 2000 papers a year, instead of charging 600 article processing charges, they charge 2, 000 article processing charges, and that sort of annoyed him and he.

Patrick: The event that I think really pissed him off. I don't know if you can say pissed him off on a surgical you can say much worse. He submitted an article

to a journal and they said, well, we don't want this But our sister journal downstream might be interested. And by the way, if you go that route, they'll charge you 3, 000.

Patrick: And he was like, well, why should I be paying 3, 000? These are very profitable companies. And why am I footing the bill? Which is another equity question. The future that I see Is and that Chris and Joe Ross, who is at Yale and Joe is one of the founders of Med Archives. So there's a he fully understands the the preprint platforms.

Patrick: This is what we see happening and you pointed out from the top. I've been an author. I've been on an editorial board. I've been contributing writer and now I'm an associate editor or a deputy editor at JGM. So I've seen the publishing and the only thing I haven't done has been on the print the print presser to put out the the actual printed copies.

Patrick: So I've seen a lot of this industry Over the course

of my well, I saw my first patient in 1976. So, and the viewers can't see, but I have gray hair. And so I've seen a lot of this. And I think that. This is how it's going to unfold. And Joe and Chris and I came up with this paradigm. It wasn't, the idea wasn't original to me.

Patrick: The leading journals, the New England journals, the JAMAs and New England Journal, I don't think charges artificial processing charges but the the other, some of the other ones do. The leading journals will exist into the future. Indefinitely. And that's because they will be the source of what is perceived to be the premier output of biomedical researchers.

Patrick: That will be where the best work will be done, and they can charge anything they want, and people will pay it. And for the most part, They will get people to do peer review. It's not just that the

content is free, but the thing that makes peer review journals valuable gives them their cachet, is the peer review part of it.

Patrick: And they also get that for free. The editors are often paid. I don't get paid at a small journal. But the peer reviewers do it for free. And, Now, as a deputy editor for Journal, General Journal Medicine, which I've been for maybe five years now I can see how much harder it is to get people to do peer review.

Patrick: They just aren't willing to do it. For good reason. In the old days, They did it out of a sense of altruism and community contribution. And the secondary reason was they often thought, well, if I review this paper for you, maybe you'll be nicer to me when I send in my paper. That's actually completely untrue.

Patrick: There is no transactionality in this, but I think some people might be naive enough to think that. Even I think that sometimes. When I get a paper from the New England Journal and they want me to

review it, I'm like, I turned that down a lot less easily than from a lower level journal. But at the journal I'm trying to mention, I used to have to put out 10 invitations to get two or three peer reviews.

Patrick: That would have been five years ago, pre COVID. Now I have to put out 25 invitations to get two or three reviewers. And most people just write back, flipping me the third finger. Who do you think you are asking me to spend my time on your paper? And I get that. I understand. People are busy, especially, it's challenging.

Patrick: It's challenging to be a junior faculty member. It's challenging to be a resident. People have families. They have the dog to watch, to walk. They have the baby to feed. Or they have parents to take care of. Or they have partners that need attention. Or they want to go on a date. So people are busy. I get that. So it's much harder to get the peer review

that we want, and it's falling maybe on a smaller number of people who are willing to who are willing to do that. So if the journals are charging article processing fees, and the peer review isn't so forthcoming.

Patrick: It takes longer to get your articles reviewed at second tier and what I would call mom and pop journals third tier journals, which don't have extensive staffs. And so, I think the future is going to look like this, the top tier journals will always be in business and they can charge what the market will bear, which will go up and up and up the second tier journals.

Patrick: Scientists are going to say to themselves, do I really want to spend another year? Walking this through the Journal of General Internal Medicine, and the Journal of Hospital Medicine, and then and even the Canadian Journal of General Internal Medicine. Do I really want to spend a year going through three second tier or pom and pop journals?

Patrick: Why don't I just put it on a pre print server like

MedArchives and call it a day? And it'll come out. Well, like tomorrow instead of a year, and I can put it on my CV and my department chair who has changed from the gray haired medical giants of the past to the hip social media. technology technology adopters, early technology adopters, and they will say, you know what?

Patrick: It makes more sense to be efficient in your career. So why don't you try New England Journal, Annals of Internal Medicine, and call it a day, and just put it on MedArchives, and put that, and we will count that as a peer reviewed journal, the equivalent of a peer reviewed journal, because guess what? The peer review you get from a mom and pop journal ain't so great anyway, and Med Archives provides a different kind of peer review.

Patrick: Instead of the peer review

being behind a wall that nobody can read it, although some journals do now publish their reviews, it'll show up on the internet. As the comments that accompany your paper on med archives, and you can see what everybody thinks of your paper after the fact, instead of hiding the peer review.

Patrick: And I predict that the metric for promotion will change from peer, any peer review journal. to top tier peer reviewed journals, and just getting it out there. Now, will there be fraud when this happens? Absolutely. But there is now. Will there be work that is mistaken? Conclusions that are honest mistakes?

Patrick: Well, there's tons of that now. Will there be crappy papers published? Well, even the New England Journal and JAMA, they're on some occasions publish work that's fraudulent that was discovered in that whole Africa thing during COVID or is wrong. It turns out to be just plain wrong.

And sometimes it's just the play of chance because these are experiments and that'll happen anyway.

Patrick: Will it be worse? Will it be better? I don't know, but it might be more efficient for investigators. I have some friends in data science who who that's what they do. They publish a paper on the data science equivalent of med archives. They put it in their CV with a link and that's the citation.

Patrick: And I think that's where we're headed in medical publishing. The key variable here will be the leadership's recognition of the efficiency of doing this. And encouraging their faculty to change from getting into a peer review journal at any cost and saying, just try the top two and put it online afterwards.

Patrick: I was a I came my academic background as you noted, was in the Department of Economics at MIT. And they published a series called the white papers in economics from MIT. And you know

what? It was not peer reviewed. It was not published. It was printed on mimeographs. And that was very prestigious to have a white paper in the economic series at MIT.

Patrick: And that's what I think we're going to go back to. Yeah. I think that the alternative publishing options is really important and pretty relevant because at least in the mathematics, the physics world, people publish things on archive all the time.

Patrick: And I know even in my sister's resume and things like that, she has citations to archive. And for them, it's, almost as prestigious to a certain degree. And they treat it just like they would treat any other piece of research. So, I wonder how long it will take for medicine. And do you think that we're getting there with, it'll take, here's how long it'll take.

Patrick: It'll take as long as you get to be chair of surgery somewhere. The current generation of clinicians and scientists are digital natives, right. Or coming up as digital natives. And so this type of Platform that you're talking about is really second nature. And if you can Dr.

Patrick: Dicey expand a little bit

on what med archives is. And the social aspect of the quasi peer review, or at least the comments, that's very much in line with what we see on social media feeds day in and day out.

Patrick: So I think I've only had two papers on med archives. And I've never actually looked at them. I know we sent them in. It would be my younger co authors said, why don't we just put some in archives? I'm the kind of guy who never gave up. Like, I might have 10 papers in my file fold in my filing cabinet where I wrote them and didn't didn't publish them.

Patrick: I would go to the ends of the earth. So I was one of those guys. If it took me four years, I didn't care. I was very persistent. But Mike Freilich, one of my younger investigators, after two tries on a paper that we were working on, said, why don't we just put this on MedArchives? And I was like, okay.

Patrick: Like, I mean, I knew what it was. So MedArchives is a preprint platform. They would not call themselves a journal. And it was started by

Harlan Krumholz and Mike Freilich. and Joe Ross at Yale, and it copied archives that were, was mentioned before. And there's another one I think called bio archives or something like that.

Patrick: And the model is that you send Your paper to them to their site, and they adjudicate not the content of it, but they there are some logistical things that you have to satisfy to make sure that it really is a paper. And I believe it's only research papers. There's no commentaries or reviews. It's just research.

Patrick: And if it passes through that screen then it gets put up on a data site that is maintained by them called med archives that anybody can access open access. and people can make comments on it. And so it's like social media with a lot more characters and a little bit of a filter at the beginning.

Patrick: And Joe and Harlan started this, maybe seven years ago, I'm guessing

at that. And it has really exploded. And in fact, Joe told me that somebody once said to him, Joe, you're a, can you say this word on your show? Joe, you're a schmuck. That's what my father would say. Why didn't you charge 50 bucks a a submission?

Patrick: If you had charged 50 bucks a submission, you'd be rich now. And he said, that's true. But that wasn't the point. So they got, I believe they got grants to start this because it's not costless because they actually have to maintain the site and maintain the data. And there is some, as I mentioned, some um, filtering of it, and that's what it is.

Patrick: But there's, this occurs in basic sciences like physics and this occurs also in data sciences. This is not new. We in biomedical science are quite a bit behind the other scientific fields. And That doesn't totally surprise me. I wouldn't expect every

field to look the same in academics.

Patrick: Just to piggyback off that the thing about archive is that it was always free and same with, medical archive as well. So one question I have to use. When you pay to publish in some of these sister journals, for example, or open access journals, do you have any sense of what exactly their costs look like?

Patrick: And what they're charging for and what value they add to that process? All right. Well, now I'm going to give you the answer that Robert solo probably taught me when I took a sophomore economics, the costs are anything you want them to be, because it depends on whether you're talking about the average cost.

Patrick: in which case you would take your total cost per year and divide it into, divided by the number of papers that you put out there, or the marginal cost, which is how much does it cost you to put the last one out there, or whether you are a monopoly and can jack up the cost to any number you want it to be.

Patrick: So I could make that

number be any number I want it to be. The costs that they, they are not recouping costs at the margin. Those dollars Are much more than the cost of the margin, but they might also not be recouping their average costs, which might in fact be higher than that.

Patrick: So there might be some subsidy, for example, from a professional journal or from profit. There might be cross. Cross subsidization from other journals, which are feeders. There might be relationships. So when they put out a number of 3000, they're not putting out what their costs are. You can be sure of that.

Patrick: They're putting out what they think they can get out of you. And then they scale it back by offering people in low income countries a waiver. They offer oh, aren't we, like the, like drug companies say, call us. And we will who makes Humira? AbbVie. I love their ads. Call us, AbbVie will make it free for you.

Patrick: Well, it's not free, you know, it's not free.

So what they're saying there is you can't afford to pay anything. So we will give it to you for free. We'll give it to the next guy for 10. The next guy for a hundred dollars and the next guy for 4, 000. And the actual marginal cost of producing this might be 5.

Patrick: So, What the number that they're putting out there is a reflection of what they think that the market will bear it's what they think the demand will cover the actual cost can be any number you want it to be. We talked about these outrageous profit margins of even 30 and 40 percent like the big tech companies and certainly not all journals.

Patrick: In fact, the vast majority probably are not making those types of margins. And so I imagine that it's not all sunshine and rainbows when it comes to money in and expenses. But to that end, there's also this proliferation of journals. So there has to be some type of economic incentive........

Patrick: I might as well mention this here. We don't talk about this in our paper. In fact, we exclude these, but there is a category called predatory journals.

Patrick: And I'm sure that both of you get emails from high,

like they make up a name, the new England journal of almost medicine. Which makes it sound like the New England Journal of Medicine. We're the New England Journal of almost medicine. And we want, would love to, we've read your paper on publications and the publishing industry, and we would love to publish a paper of yours.

Patrick: Will you submit something to us? And by the way, it'll cost you 3, 000 and you can put it on your CV. Those I believe are called predatory journals. And that's a huge growth industry in itself, like they put nothing into it and it's all profit for them. That's not really what I'm talking about here.

Patrick: What I'm talking about here is networks of journals that, like JAMA, down to JAMA Open where JAMA doesn't charge a processing fee, but JAMA Open does and, or CMAJ, Canadian Medical Association Journal does, well actually they do charge an article processing charge, and then they also have an open version of it as well.

Patrick: I'm talking about real journals that really do have some effort to have peer review in them. The other ones are

not. But there's no barriers to entry for this, like, I probably shouldn't tell you this, but I will many years ago when I was on the editorial board of the New England Journal of Medicine there were two really controversial events.

Patrick: I'm just gonna tell you about one of them. The journal itself wanted to multiply. It was a, an entity of the Massachusetts Medical Society. It was, whether it had profits on the books or not it was a lucrative entity for the Massachusetts Medical Society. And like the Wisconsin Medical Society wouldn't be as profitable because they don't have the Wisconsin Journal of Medicine that would be of equal stature to the New England Journal of Medicine.

Patrick: And they wanted to expand their brand and create subjournals, New England Journal of Medicine, Internal Medicine, New England Journal of Medicine, Neurology, like that kind of thing. Those weren't the names they were going to use. And the editors. At the time where Jerry Kassir, Marsha Angel and Bud Relman was the past editor, they

resisted that.

Patrick: They thought that was a bad move, that it would water down the product. And there was a big fight between the medical the Massachusetts Medical Society and them. And ultimately, they didn't renew Jerry's contract. And at our editorial meeting, the editorial board was of course supportive of the current editors and said to themselves, well, maybe we should all quit and open up our own journal called whatever brought to you by the former editorial board of the New England Journal of Medicine.

Patrick: And I said, Nobody gives a fuck who we are. Like, they don't even know our names. Like, if we said, brought to you by the former editors of the New England Journal, editor, editorial board, nobody would care about that. It's the brand that matters. And we wouldn't even be able to use that because we'd be infringing on their brand.

Patrick: So that idea is a non starter. And that, and they changed editors and, you know, Jerry had been in the job for 10 years and

maybe it was time anyway. And Jeff Drazen came in and He has been, was an active promoter. He's a smart guy, like really good guy. He promoted this and developed it, and now he's passed it on to the next editor, Eric Rubin, and he's still involved, and they were able to leverage their reputation onto these lesser journals.

Patrick: They aren't as good. It's not as prestigious. And they don't have the same quality of work, but they have the brand name. And so it is a vehicle for disseminating research just as the JAMA group did. And it was a good idea. You know, JAMA originally had the sub journals of JAMA were called the archives of internal medicine.

Patrick: There was Journal Medical Association, and then there was the Archives of Internal Medicine, which was also published by the American Medical Association. And quite smartly, many years ago, they said, that's not capitalizing on our brand. So why don't we change the name of that to JAMA Internal Medicine?

Patrick: And it was it was a brilliant

move because then there was JAMA surgery and JAMA dermatology and JAMA neurology and and that standardized the brand, which gave them I think better better ability for the lesser journals to to market themselves. One last question I have for you is for a resident today, let's say like me, you're doing a two year research fellowship, you want to publish a small paper, you have two years to do it.

Patrick: Let's say that I get rejected for some of the top ones that you spoke about, if I was to publish into a meta archive scenario right now, how would that look if I'm applying to a fellowship. Or even at Duke today. Do you think that we're there now or not quite? No, we are not there now because the Fuddy Duddies who run academic medicine are still stuck in the old model for the most part.

Patrick: Well, Dr. Deskey, this has been a fantastic conversation. We really appreciate your time and having you on. So this is Alan Detsky from Toronto, Ontario, Canada, signing off and

telling you all to dominate the day.