Education and debate
Key learning point
Training of medical staff involved in the giving of
transfusions by transfusion service staff can improve
compliance with guidelines on identification and
monitoring of patients receiving transfusions
Conclusions
Dissemination of best practices to those who administer blood by those who crossmatch and provide it is
successful in promoting safe transfusion practice. Such
education programmes are an effective strategy to
reduce the risks associated with transfusion. Success
may be enhanced by employing a nurse solely for
transfusion support. We do not know how long the
effect of the current intervention will last but we anticipate that the nurse instructors in each clinical area will
have a continuing effect. We intend to carry out a
further audit in due course to determine if and when
further interventions are required to maintain the
current high compliance with published guidelines.
PC carried out the collation of data and the statistical analysis. IR
assisted in the development of the project and the educational
material and carried out the audit work and teaching. SR
conceived and directed the local implementation of the project.
All three authors cooperated in the preparation of the
manuscript.
Funding: This initiative was funded by the Scottish National
Blood Transfusion Service and was recognised as a Clinical
Governance Priority for this by the Tayside University NHS Trust.
Competing interests: None declared.
1
2
3
4
5
6
Love EM, Williamson LM, Cohen H, Jones H, Todd A, Soldan K, et al.
Serious hazards of transfusion (SHOT) annual report, 1999-2000. Manchester: SHOT Steering Group, 2001.
British Committee for Standards in Haematology, Blood Transfusion
Task Force, in collaboration with the Royal College of Nursing and the
Royal College of Surgeons of England. The administration of blood and
blood components and the management of transfused patients. Transfusion Med, 1999;9:227-38.
Van den Arend IJ, Stolk RP, Rutten GE, Schrijvers GJ. Education
integrated into structured general practice care for type 2 diabetic
patients results in sustained improvement of disease knowledge and selfcare. Diabet Med 2000;17:190-7.
McClelland B, ed. Handbook of transfusion medicine. 2nd ed. London:
HMSO, 1996:30-40.
Rowntree D. Preparing materials for open distance and flexible learning. An
action guide for teachers and trainers. London: Kogan Page, 1996.
Dinc L, Erdil F. The effectiveness of an educational intervention in changing nursing practice and preventing catheter-related infection for
patients receiving total parenteral nutrition. Int J Nurs Stud 2000;5:371-9.
(Accepted 25 June 2001)
Navigating across medicine’s electronic landscape,
stopping at places with Pub or Central in their names
Tony Delamothe
BMJ, London
WC1H 9JR
Tony Delamothe
editor, bmj.com
tdelamothe@
bmj.com
BMJ 2001;323:1120–2
Attempts to use the internet to free up access to the
world’s biomedical literature have resulted in several
similarly named initiatives emerging over the past two
years. PubMed Central, BioMed Central, and the Public
Library of Science have joined the slightly older
PubMed, which has a different function but a name
similar enough to add to the confusion.
The debates around free access are some of the
most important that have taken place in the three centuries of scientific publishing.1 Yet confusion about who
wants to do what to whom is hampering this debate.
This attempt to dispel some of the confusion was up to
date at the time of writing, but given the speed at which
medicine’s electronic landscape is changing, it is likely
to date fast.
Summary points
Several initiatives have recently emerged to
provide free access to biomedical literature
though the internet
Traditional publishers have been reluctant to join
these initiatives because of fears about lost
subscriptions
PubMed Central’s “decentralised model” could be
the trigger for greater publisher participation
The advent of free electronic journals—paid for
by authors’ charges—could profoundly change the
publishing landscape
PubMed
PubMed provides access via the world wide web to over
11 million Medline citations dating from the
mid-1960s to the present. It covers 4300 journals
devoted to medicine, nursing, dentistry, veterinary
medicine, healthcare systems, and the preclinical
sciences. PubMed also provides access to life science
journals that are not indexed by Medline but have submitted their full text to PubMed Central (see below).
As well as providing access to these abstracts and
citations, PubMed links to more than 2000 websites
that provide full text articles (figure). Access to these
full text articles usually entails registration, subscription fees, or some other form of payment, although
bmj.com is free.
1120
In the four years since PubMed was launched as
Medline’s web interface, it has become the starting
point for literature searches for most medical researchers. Over one million searches are conducted through
PubMed each working day. A service provided by the
US National Library of Medicine, PubMed is paid for
by the US taxpayers.
Decisions for authors
In terms of exposure, publishing original biomedical
research in a journal not indexed in PubMed is akin to
sealing a manuscript in a bottle and launching it on the
tide. For authors, it’s publish in a journal indexed by
PubMed or perish.
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Education and debate
Decisions for publishers
Research journals that want to be taken seriously need
to appear in PubMed. The main route in—acceptance by
Medline—is difficult. Only 15-20% of applications to
Medline are successful, and the process can begin only a
year or two after publication of a new journal. The fact
that publishers can leapfrog this hurdle by agreeing to
submit the full text of articles to PubMed Central has
fuelled publishers’ grievances against PubMed Central.
Should Medline level the playing field by being less
exclusive? Arguments about constraints on space in the
paper world do not apply online.
PubMed Central
As its name suggests, PubMed Central is an extension
of PubMed and is similarly funded by the US taxpayer
through the National Institutes of Health. Whereas
PubMed provides free access to bibliographic citations
and abstracts, PubMed Central provides free access to
the full text of peer reviewed articles.
Suggested in 1999 by Harold Varmus, when head
of the US National Institutes of Health, PubMed
Central became operational within a year. In its first
iteration, the full text of original research articles had
to be made available from PubMed Central some time
after publication. Fearing lost subscriptions, most publishers sat on their hands and hoped it would go away.
Given this negative reception, PubMed Central proposed an additional “decentralised model” earlier this
year. Although publishers must still send the full text to
PubMed Central—to allow for sophisticated searching—
PubMed Central could route users back to publishers’
sites to access the full text. Publishers have to guarantee
free access to this material within a year of publication.2
Few journals are currently available on PubMed
Central. These are BMJ, Bulletin of the Medical Library
Association, Molecular Biology of the Cell, Plant Physiology,
Proceedings of the National Academy of Sciences of the
United States of America, and 55 journals published by
BioMed Central (see below). Another dozen have
pledged to participate. None is yet available in the new
decentralised format, but 17 journals have either
signed up or indicated that they will participate
(Ed Sequeira, personal communication).
Decision for authors
Most researchers want to maximise exposure to their
work and the credit that it brings them. However, in a
world where ever more material is read by ever fewer
people, the standing of the journal in which a study
appears is widely used as a proxy for the quality of the
study itself. (Research assessment exercises have led
the way here.)
Although PubMed Central clearly satisfies
researchers’ aspiration for exposure, the nonparticipation of most high status journals threatens the
credit that could accrue to authors. Authors therefore
have a difficult decision: by publishing in journals that
have signed up with PubMed Central they might
increase the chance that future researchers would have
free access to all scientific literature—but at the cost of
damaging their own careers.
Decisions for publishers
Publishers’ initial response to PubMed Central was a
staunch defence of the status quo. Researchers may
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Screenshot of abstract of a BMJ article on PubMed, showing its Link Out facility. In this
example, the blue button links directly to the full text of the article on bmj.com
conduct and write up the research as well as peer
review and edit articles, but publishers expected to sell
the results of their labours back to them and their
librarians at a substantial profit.
The first iteration of PubMed Central apparently
threatened subscription revenue: if readers could find
the full text of original articles on PubMed Central
then neither they nor their librarians would need to
subscribe. Yet this first iteration placed no limit on the
time between journal publication and its subsequent
appearance on PubMed Central. The gap could have
been as long as two years—hardly likely to affect
subscriptions.
Even before PubMed Central was mooted, many
journals were giving free access to their original
research articles one or two years after publication.3
But PubMed Central was certainly a spur to such activity, with the New England Journal of Medicine admitting
as much when it announced its decision to give free
access to its original research articles six months after
publication.4
From the user’s point of view, the combination of
free archives available from journal websites and
PubMed’s Link Out facility (figure) looks very much
like PubMed Central’s decentralised model. Yet
publishers seem as reluctant to embrace this model as
they were the original model. This is despite the advantage of having a journal archive maintained by
PubMed Central, thus addressing librarians’ main concern about electronic journals—that publishers can’t be
depended on to maintain electronic archives.
BioMed Central
BioMed Central is an independent publishing house
that aims to provide immediate free access to peer
reviewed biomedical literature. It publishes all articles
deemed scientifically sound simultaneously on its own
websites and through PubMed Central.
BioMed Central provides a quick route on to
PubMed Central for authors disenchanted with traditional journals’ slow peer review process and their
practice of charging users for the finished product. It
1121
Education and debate
Public Library of Science open letter
We support the establishment of an online public library that would provide
the full contents of the published record of research and scholarly discourse
in medicine and the life sciences in a freely accessible, fully searchable,
interlinked form. Establishment of this public library would vastly increase
the accessibility and utility of the scientific literature, enhance scientific
productivity, and catalyze integration of the disparate communities of
knowledge and ideas in biomedical sciences.
We recognize that the publishers of our scientific journals have a
legitimate right to a fair financial return for their role in scientific
communication. We believe, however, that the permanent, archival record of
scientific research and ideas should neither be owned nor controlled by
publishers, but should belong to the public, and should be freely available
through an international online public library.
To encourage the publishers of our journals to support this endeavor, we
pledge that, beginning in September, 2001, we will publish in, edit or review
for, and personally subscribe to, only those scholarly and scientific journals
that have agreed to grant unrestricted free distribution rights to any and all
original research reports that they have published, through PubMed Central
and similar online public resources, within 6 months of their initial
publication date.
does this in two ways—through its own electronic
journals and by giving groups of scientists the ability to
set up electronic journals under their own editorial control. Most of BioMed Central’s large stable of electronic
journals began publishing within the past 18 months; all
of them are indexed by PubMed, even those that are yet
to publish an article. To pay for this service, BioMed
Central is considering introducing authors’ charges of
$500 (£330) per accepted article from next year.5
Decisions for authors
Publishing in a BioMed Central journal gives
interested readers free access to the full text article as
soon as it is published—a potential increase in
exposure compared with publishing in more restrictive
journals. But like all new entrants, BioMed Central’s
journals have yet to establish themselves as prestigious
destinations for authors, for whom impact factors
loom large. Understandably, BioMed Central is “working to develop additional methods for judging the
relative importance of particular pieces of research.”6
Decisions for publishers
Publishers need to decide what to do in response to the
BioMed Central “experiment.” Should they ignore it,
emulate it, or buy the company—if they believe it is
several years ahead of the curve?
nal had committed itself to free distribution rights after
six months. Even BioMed Central, whose journals head
the Public Library of Science’s list of those that have
come closest to adopting its policy, retains exclusive
rights to commercial reuse of material in its journals.6
Decisions for authors
As signatories would have had no journals to publish
in, edit or review for, or personally subscribe to from
September, the Public Library of Science recommended that signatories should “make every effort to
publish our work in, and give our full support to, journals that have adopted the policy proposed in the open
letter.” (Policy, here, apparently does not extend to
“unrestricted free distribution rights.”) But resistance
from most publishers “has made it clear that if we really
want to change the publication of scientific research,
we must do the publishing ourselves.” So the library
will launch its own journals. Author charges of about
$300 per published article are expected to cover the
costs of peer review, editorial oversight, and publication. Unrestricted rights to access, distribution, and
use of all articles will be assigned to the public domain.
Decisions for publishers
Although many journals are now freeing up access to
their articles soon after publication, they are still
guarding their commercial rights beyond that. Compliance with the demands of the Public Library of Science
could mean losing revenue from reprints of articles
more than six months old, for which pharmaceutical
companies pay medical journals substantial amounts
of money. Should they forgo this income to comply
with these demands? Or will the arrival of the Public
Library of Science’s own journals mean action is
already too late?
Conclusion
The current practice of scientific publishing results
from the balance of power among authors, funders of
research, publishers, academia, and the alliances
between them. As the great disrupter, the web seems
likely to confound the status quo, although exactly how
is hard to predict. The wheel is still in spin.
Key players
PubMed
www.ncbi.nlm.nih.gov/entrez/query.fcgi
PubMed Central
http://pubmedcentral.nih.gov
BioMed Central
www.biomedcentral.com
Public Library of Science
www.publiclibraryofscience.org
Public Library of Science
Sharing some of the same architects as PubMed
Central, the Public Library of Science is a pressure
group best known for its open letter (box), which has
attracted more than 28 000 signatories from 172
countries. The last paragraph of its letter is crucial. It
states that signatories will publish in, edit or review for,
and personally subscribe to only those journals that
have agreed to grant unrestricted free distributions
rights to all original research within six months of publication. What many signatories and publishers may
not have grasped is that “unrestricted free distribution
rights” means exactly what it says: six months after
publication anyone should be able to reuse any
material, for any purpose—including commercial ones.
By the library’s September deadline, no scientific jour1122
1
2
3
4
5
6
Future e-access to the primary literature.www.nature.com/nature/
debates/e-access/index.html (accessed 16 October 2001).
Sequeira E, McEntyre J, Lipman D. PubMed Central decides to decentralize. www.nature.com/nature/debates/e-access/Articles/pubmed.html
(accessed 16 October 2001).
Free online full-text articles.http://highwire.stanford.edu/lists/freeart.dtl
(accessed 16 October 2001).
Campion EW, Anderson KR, Drazen JM. A new web site and a new policy.
N Engl J Med 2001;344:1710-1.
BioMed Central. BioMed Central to consider charging authors for paper
submissions. Press release, 29 June 2001. www.biomedcentral.com/info/
pr-releases.asp?pr = 20010629 (accessed 16 October 2001).
What is BioMed Central? www.biomedcentral.com/info/whatis.asp
(accessed 16 October 2001).
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