Publishers’ charges for scoring systems may change clinical practiceBMJ 2015; 351 doi: https://doi.org/10.1136/bmj.h4325 (Published 12 August 2015) Cite this as: BMJ 2015;351:h4325
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The author is right to flag up the problems posed by an increased tendency towards monetisation of clinical scoring systems.
However, in the case of the MMSE, I am of the opinion that the publishers' retrospective copyrighting of a 40-year old test has had positive consequences for clinical practice.
The author cites anecdotal evidence that the "MMSE is no longer used even in memory clinics". Given that the MMSE only contains one memory item (three words recalled at approximately a minute's delay), it can hardly be seen to even scrape the surface in terms of memory assessment. It is also deficient in assessing other areas of cognition such as executive functioning.
In light of the availability within the public domain of other, better-balanced, well-validated screens such as the Addenbrooke's Cognitive Examination, Third Edition (ACE-III;) , or the Montreal Cognitive Examination (MoCA), it is high time that the MMSE is ushered towards a place of venerable retirement alongside other outmoded instruments. I believe that the publishers have done us all a favour by forcing us to consider alternatives, and thereby easing it on its way.
Competing interests: No competing interests
Fern highlights an important element of copyright law, which is increasingly affecting doctors. The motives of NICE and various medical journals with restrictive copyright practices are actually in many ways laudable. Such exclusive intellectual property rights are generally intended for instances where scoring systems are used in commercial material such as books to be sold, as in the case of Fern’s endeavour. Under such circumstances the book’s authors may enjoy considerable financial gain, in part by reproducing validated scoring systems, yet the originators of these clinical tools and publishing journals gain nothing. For example NICE’s standard copyright terms are explicitly prohibitive of reproduction of material by commercial organisations or for commercial purposes without written permission, but allow educational non-profit replication of material(1).
Journals and national guideline authorities appear to want financial as well as intellectual recognition; in a similar way to which an author desires financial remuneration, even for textbooks intended for medical education. Hence they require that reproduction or distribution of material be by express permission of the journal or publisher. However the very strict enforcement of copyright, in the field of medicine and science is now antiquated and counterproductive. The law has evolved. The exclusive copyright paradigm employed by NEJM and Annals is too blunt a tool to achieve the desired goals. Its net effect is that there is little dissemination of clinical tools or the process is excessively slow such that clinical utility and potentially even clinical care is affected.
Copyleft is not a legal term but a “jeu de mots” which reflects this principle of liberal licencing intellectual property. Its advantage is that authors can allow unfettered clinical or non-profit use, modification and/or reproduction but simultaneously give commercial users a licence to use their work for a fee. The Lancet Global Health explicitly uses a form of copyleft licensing known a “Creative Commons Licence”. The following website: http://creativecommons.org/ is used by the journal. Lancet Global Health gives authors the latitude to determine how permissive or restrictive the “copyleft” license. Individual or independent authors can also use the sight to tailor “copyleft” licences to their own needs. With this copyleft model authors and journals need not be afraid of intellectual or financial appropriation of their work; thereby ensuring that their primary motivation of improving patient care is not obstructed by these apprehensions. This important contribution of Fern also allows the BMJ to consider is its copyright model, which vacillates between a “copyleft” (Creative Commons Attribution +/- Non Commercial) licence for “Open Access” submissions but remains as restrictive as Annals and NEJM for third parties (i.e. those other than the journal and author) for other publications (4).
(1) http://www.nice.org.uk/guidance/ng19/resources/diabetic-foot-problems-pr... (page 45 of guidance bottom)
(2) Newman JC, Feldman R. Copyright and open access at the bedside. N Engl J Med. 2011 Dec 29; 365(26):2447-9.
Competing interests: No competing interests
Yes, this is a growing problem in medical publishing that is anti-scientific and not in the best interests of patients. For the MMSE, it seems unrealistic to require that medical students, physicians, and other health professionals pay a licensing fee to obtain a simple question and answer screening test, or pay for each test administered using a mobile application. (1) Many patients will risk going unscreened and unidentified, and perhaps not receive the interventions they should.
But the problem is worse, because it extends beyond scoring systems. I’m editor of American Family Physician, which publishes clinical review articles. Such articles often incorporate tables and figures from other journal articles. Permission fees have become exorbitant. One table had 40 words, and the permission fee requested was $4,400—more than $100 per word! One journal wanted almost $5,000 for a table of drug therapy that largely consisted of product labeling information (in other words, public domain information).
This practice seems driven totally by profit motives, and goes against the dissemination of medical knowledge designed to help patients.
Jay Siwek, MD
Competing interests: I'm editor of American Family Physician, which pays permissions fees and charges permissions fees for republished material.
Many Cochrane Reviews recommend that future clinical trials use validated outcome measurement tools. I hadn’t thought before today that trialists might not be doing this because of costs! What a tragedy.
I can only think that institutions are forced in the current financial climate to make money out of research in this way which then prohibits the proper tools being used as research funding is cut. The knock on effect is that we can’t do fair evaluation across a number of trials, we write more research is needed and so the merry-go-round continues.
Competing interests: I am the Managing Editor of Cochrane Airways. These thoughts are my own and do not necessarily reflect that of my colleagues or the group's funders.