Will Knols and Blogs Upend the Cozy World of Medical Publishing?

By  |  July 25, 2008 | 

Yesterday, Google launched Knol, immediately branded as Google’s answer to Wikipedia. As healthcare advisor to the project, I’ll say a few words about Knol, but focus on how it – and other forms of electronic self-publishing – may signal the end of medical publishing as we have known it.

First, a word about Knol (the name is short for “a unit of knowledge”). Google’s vision is that providing a tool for people to write about “things that they know” will make the world a better place. Unlike Wikipedia’s anonymous, collaborative writing/editing process, Knols have authors, with names, faces, and reputations. (Authors can choose to have their identity verified, through a cross-check on their credit card or phone records.) Google provides Knolers a tool; authors enter their content and click “publish.” And poof, there it is, on the Web. Users can rate and comment on Knols, send them to friends, and suggest changes. But the author remains the sole owner of the content, able to update and modify it (or remove it) at any time.

That’s where “Search” comes in. There is no real “Knol website” – Knols will appear as results in Google (and presumably other) searches; according to Google, the search position of Knols on their search engine will be determined by the usual Google algorithm, with Knols having no advantage over other information sources (a claim that has been met with some skepticism in the Blogosphere, but one that I believe).

Enter the issue of money, probably the most controversial aspect of Knol. Authors can, at their discretion, choose to allow Google to post ads on their Knols (using Google’s AdSense service). If they do, the authors receive a share of the revenue stream. How much? Nobody outside the Googleplex knows for sure, but the overall revenue will be determined by search popularity and position. So, the thinking goes, experts have an incentive to write terrific Knols and keep them updated in order to maximize their ad revenue.

The Blogosphere is again atwitter with discussion of Knol (for example, see here, here, and here) – much of the discussion surrounding whether Knol is a Wikipedia Killer. Wikipedia, run by a foundation with authors writing presumably for the Good of Mankind (authors and editors are not compensated), is generally characterized as the White Hat in these comparisons. Some observers, though, note that certain Wikipedia entries show clear (but untraceable) corporate influences or other biases, biases that would presumably be more transparent on Knol because of the defined authorship. Most of the reviews of Knol have been pretty positive, and the general sense is that there is probably room for both Knol and Wikipedia to do well. The Internet is a big place.

What was my role in all this? Though there will ultimately be Knols on everything from unclogging a toilet to eclipses (in fact those Knols already exist, here and here), Google thought it would be a good idea to launch the project with a set of Knols on a popular topic already written. They chose healthcare as that topic, and asked me to develop the list of subjects and recruit the authors, which I did – about 300 subjects in all. (Full disclosure: I received compensation from Google for my work.) So if you search Google for your favorite healthcare topic (migraine, or MI, or leukemia, for example), you’re likely to see a Knol – at this point, undoubtedly one that I commissioned – in the search results. The Knols are layperson oriented: I asked authors to write the Knol that they’d want their mother or best friend to read if they had just been diagnosed with the illness. There are also a few Knols on broader medical issues; for example, I wrote Knols on patient safety, quality of care, and hospitalists.

The rationale for this starter set was not only to have an existing set of Knols at the time of public launch, but also to help Google work through all the technical glitches, and at first there were many. There are still a few, but overall the tool works very well and will undoubtedly improve over time.

With that as background, let’s examine how Knol – and other forms of electronic self-publishing such as blogs – may disrupt the traditional world of medical publication.

The disruptive impact of the Internet on the publishing businesses is well appreciated. Newspapers are dying on the vine, venerable textbook publishers are reeling under the competitive pressure of new web-based resources, and most journals have scrambled to make their content available on-line. But, even as they accommodated the changing preferences of readers, traditional print journals and textbooks (in healthcare, at least) have not yet been rocked by competition for content. I believe that this is about to change.

Until recently, if I or another author had a research study or a thought piece we wished to disseminate widely, our only avenue was a traditional medical journal. The act of submission required that we relinquish ownership of the intellectual content to the journal’s publisher. For instance, here’s JAMA’s copyright waiver:

“In consideration of the action of the American Medical Association (AMA) in reviewing and editing this submission… I hereby transfer, assign, or otherwise convey all copyright ownership, including any and all rights incidental thereto, exclusively to the AMA, in the event that such work is published by the AMA.”

Yada yada.

That authors voluntarily signed away their intellectual content is remarkable. Think about it: many researchers spend hundreds, even thousands, of hours creating a “product,” and then hand it to a third party without compensation. (Of course, in the United States substantial amounts of research have been funded by tax dollars, with its implied obligation to pursue publication.) In exchange, journals agree to perform peer-review, which – in the case of major journals like the New England Journal and JAMA, with acceptance rates similar to Princeton’s – is likely to end in rejection after a 1-3 month review process. After a few spin cycles (submission, review, rejection, submission elsewhere, review, revision, re-submission…), most articles are accepted – somewhere – and published 4-12 months after that.  

I have to believe that the major journals have been thrilled by this arrangement, which led to two salutary economic outcomes. First, individuals and libraries paid good money to subscribe, largely to read and offer this highly vetted content. Second, advertisers, desperate to reach the journals’ large and important audiences, paid premium ad rates. This virtuous cycle (from the publisher’s standpoint) hinged on the willingness of authors to submit content without seeking remuneration.  

Why did authors play ball? Because publication in a prominent journal was, and remains, the coin of the academic realm – the ticket to promotion, grants, consulting agreements, and recognition. In other words, authors voluntarily handed over their intellectual property as a loss leader, largely to establish their “brand.” (I don’t discount the importance of altruism in many researchers’ decision-making, but doubt that it, in isolation, would have generated the historical dynamic). So all academics learned to play on this particular field, since it hosted the only game in town.

Contrast that process with my routine when I write an entry for this blog. When I’m done composing, I click “Publish” and it appears on-line seconds later. I am fortunate to have a reasonably large and enthusiastic readership (thanks!), and I receive lots of feedback and recognition for my postings (my more controversial or topical posts generate more feedback – calls, e-mails, media inquiries – than I have received for anything I’ve ever published in the traditional medical literature, including in the world’s best read journals). For the moment, I have chosen not to advertise on my blog, but the point is that I could (“monetizing” the blog, in the lingo); after paying costs, the revenue would be mine.

But blogging is not without its complexities – one has to figure out the technical aspects and do some marketing. When I decided to start this blog, I asked my friends at the Society of Hospital Medicine and their publishing partner Wiley whether they would consider hosting and promoting it. Luckily, they agreed. So, in my case, a third party took care of the infrastructure and the marketing. Perhaps the journals are safe, since few authors will have access to this kind of support.

But perhaps they are not. As I described earlier, Knol allows authors to post text, pictures, videos, and more, all without breaking a technological sweat or employing a teenager. The author simply creates the content, loads it in, and clicks “Publish” – no peer review, no rejection, no delay, and no relinquishing copyright. And, from the moment they publish their Knol, authors can at least partly realize the monetary value of their content through the advertisement option.

But won’t traditional journal publishing remain the coin of the academic realm, notwithstanding these new dissemination pathways, because of the perceived value of peer review? For now, sure, but we may also witness the democratization of peer review, since readers can comment on and rate Knols. And, rather than looking at a journal’s “Impact Factor” as a proxy for the impact of an article, this blog tracks and reports the number of views of each entry; Knol might ultimately do the same, but for now I can estimate how widely read and linked a Knol is by where it comes up in a Google Search.

In other words, traditional journals’ enviable position as the sole arbiters of the quality and impact of an author’s work may be challenged by web-derived measures of the impact of individual “articles,” such as number of hits, number of links, and reader ratings and comments.

You’re skeptical. And you should be. Having an article peer reviewed by 3 experts is different than having 17 Joe Six-packs (or, if I really crave positive feedback, family members) give it a thumbs up on Knol. I discussed this issue with Udi Manber, Google’s Director of Search Engineering and the brains behind Knol. “Yeah,” he acknowledged, “not all reviews are equal. But we could also rank the reviewers.” How? Lots of ways. For example, reviewers could be ranked by their number of published articles, multiplied by the impact factor of the journals their articles were published in, all determined by an instant PubMed search. Or by the number of visits to their Knols. The head begins to spin with the possibilities.

The point is this: peer review, that most sacred of academic rituals, might ultimately be replaced by real-time rankings by experts and, if you buy the Wisdom of Crowds thing, the masses. Manuscripts might be improved not by month-long editor-mediated back-and-forths between anonymous peer reviewers and authors, but by Wiki-like suggestions directly from readers to authors. And the impact of a work might be determined not by whether it was published in a widely read and cited journal, but by whether the piece itself was widely read, cited, and linked.    

Is this progress? I’m not sure. I think the traditional system has generally served us well, and has set a high bar for the quality of published content (at least in the major journals). But, as in other areas in which the Internet is democratizing and transforming commercial relationships (on-line brokerages or travel sites, for example), Knols and blogs are demonstrating that the technology now exists to “dis-intermediate” the publishing of medical research. With that, traditional journals may need to compete – and not only against other journals – for both readers and authors. Journals may find that they need to begin to compensate authors for their articles, allow authors to retain copyright, or employ other previously unthinkable strategies to remain the preferred choice for authors’ best work.  

When I first drafted this article, I chose to send it to two major medical journals rather than publish it on my blog or in a Knol. As an author, I know that the reach of these journals is virtually unmatched, and the peer review process generates an imprimatur that more personalized and democratic venues can’t equal. As a reader, I know that everything I read in these journals is of high quality, largely because of their rigorous review, editorial, and conflict-of-interest processes. As a subscriber to both of these journals, I continue to be more-than-willing to pay for this value.  

But how about tomorrow and next year? Like all aspects of the Internet, if faculty, universities, and journals want to preserve the magic of the prior system of peer-reviewed publishing, they will need to adapt and lead in this new world, not just hope that they can hold onto their prior business model in the face of these staggering technological changes.

Oh yeah, both journals turned the piece down.


  1. Bob Wachter July 26, 2008 at 5:57 am - Reply

    Thanks to “ccw” for pointing out yesterday’s announcement of the upcoming launch of Medpedia — by coincidence, on the same day as Knol launched. Here’s the official launch announcment, and here is a post from the Wall Street Journal’s health blog. Medpedia is a Wiki-like site a twist: writers/editors must have MDs or PhDs and be vetted as “experts” through a “rigorous internal review process.” And it appears that the writers/editors will be profiled on the site, like Knol. Several top medical schools (including Harvard, Stanford, and Michigan) and the UC Berkeley School of Public Health have endorsed the site, though it isn’t clear what that means for their faculty.

    Although the details remain a bit sketchy, it is clear that Medpedia represents yet another avenue for experts to disseminate their work, independent of the traditional journals.

  2. bobsnodgrass July 29, 2008 at 5:23 pm - Reply

    This is long winded- if you read it and don’t keep it on site, that’s fine with me.

    The wisdom of crowds led to uncritical acceptance of Vioxx although the first paper in NEJM clearly showed a large difference between Vioxx and Naproxen in the risk of myocardial infarction. Physicians were primed for these “wonder drugs” by their awareness of NSAID related GI problems and enthusiastic physician talks and articles such as Groopman’s New Yorker superaspirin article. And of course, we love new stuff. Likewise statins have been seriously overused although they have benefits- blogs, chats etc are lousy at putting things in perspective, saying “A is better than standard treatment for only a few patients with these characteristics”- i.e. the shades of gray so important to medicine. Why were people shocked by Tim Russert’s death in spite of modern medical care? Because they think that modern medical care would/should make us all live to age 80! Rubbish.

    I’m an academic old goat whose feelings have been hurt when some of my papers were rejected or trimmed won by journals, but I see real benefits to peer review- I review papers for several journals.

    Consider the “I know I’m right” feeling which we docs are prone to- we get a good response to mediocre treatments in part because of placebo responses to us (we all need a friendly enthusiastic physician, but our current healthcare system makes it difficult for docs to put out the time and effort to land us and our flitting from doc to doc and rumor to rumor works against building any long term medical bonds) and in part because we forget the patients who don’t come back- we don’t know their outcomes.

    There is a place for Knols; eventually a national health system will provide some automated interactive responses to queries about common health problems, just as computer makers provide automatic impersonal troubleshooting guides. You get the automated impersonal response and a reminder that everyone needs a personal physician who really knows her, reminding her to contact that physician if the problem doesn’t clear up. Then we pay something out of pocket for that personal service, although most of the health care costs would be subsidized out of tax revenue.

    You overlook the potentially valuable role of medical societies. They support many journals with their membership dues but really do little for their members. For example, Practice Parameters of societies often go overboard on new testing- cardiologists say that all kids starting a stimulant should get EKGs. The Society for Neuroscience sponsors many local chapters focused on research, sends me emails urging me to contact Congress for more NINDS funding, etc. It does nothing to decrease the simplistic overtreatment and at times fraud so rampant in neurology and psychiatry- the idea that all we do is prescribe a pill to “correct chemical imbalances” – many prey on the anxieties of older people about Alzheimer’s disease. Why don’t the medical societies have frequently upgraded web sites dealing with these practical issues? They can say that such and such is not evidence based without being vulnerable to lawsuits. Clinicians who are milking the public will use Knols to milk them further.

    A final point hat may be less obvious to you if you deal only with acute care and inpatient issues: millions take medication for hypertension, diabetes, epilepsy, depression etc. When you get a FAX asking you to refill the medicine, you usually see “date last filled”- typically it is July 12 but the FAX comes July 25- there were 13 days of no possible coverage and 30 days of (fingers crossed) medication adherence. So medication coverage was 30/43 or 69.8%. When researchers look at medication coverage for groups of patients with any chronic disease, they find it to be 50-75%. If I had those fill dates at the time of seeing the patient for a return visit (computer system opens list of tomorrow’s appointments for tomorrow, goes to a secure web site and get those dates and computes a medication coverage number) I can gently say- Eddie, you are missing too many doses of your meds. You’ve gotta do better if you want to feel better, and it can make a difference. We often separate patients into the two extremes of always adherent (good guys) and never adherent (bad guys) – most patients are in the middle, but if we could improve the medication coverage figure, this would help patients and save money.

    I’ve got nothing against the Internet sites, but I think that they mostly work to fragment medical care and encourage patients (NOT consumers) to think of themselves as atoms or plankton. When humans think of themselves as plankton they won’t stop to help others or build their community, and they often harm their own best interests.

  3. Mighty Casey January 10, 2013 at 2:36 pm - Reply

    When worlds collide! My friend Dr. Ted Eytan uses the LinkWithin widget on his site, and at the bottom of his current series on “I Am a Family Physician” a link to a 2008 post about *this* post led me over here.

    Oh, and I’m also the producer of Wiley’s Hospitalist podcast, a member of the Society for Participatory Medicine, and a big believer in the power of real evidence in evidence-based medicine.

    Closing in on five years since you posted this, Knol was taken out behind the barn and put down in May 0f 2012, and the blogosphere has continued to spray content (from terrific to terrible) about health across the universe.

    In “The Creative Destruction of Medicine,” Eric Topol takes a long, hard look at how the digital-content revolution is impacting healthcare, and offers some solid ideas on how to harness the potential for collaboration presented to science, particularly medicine.

    I’m glad to be part of the revolution, and hope to be fighting on the side of the Science Angels rather than the Snake Oil Chorus. It requires intellectual rigor, and a willingness to pursue replicable evidence, rather than offering up a single outcome instance as scientific proof.

    Deeply appreciate the work you’ve done in building SHM, and I’ve become something of a civilian expert in hospital-medicine news thanks to my ongoing work with The Hospitalist. I hope to meet you at HM13 – I’ll be podcasting from the conference.

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About the Author: Bob Wachter

Robert M. Wachter, MD is Professor and Interim Chairman of the Department of Medicine at the University of California, San Francisco, where he holds the Lynne and Marc Benioff Endowed Chair in Hospital Medicine. He is also Chief of the Division of Hospital Medicine. He has published 250 articles and 6 books in the fields of quality, safety, and health policy. He coined the term hospitalist” in a 1996 New England Journal of Medicine article and is past-president of the Society of Hospital Medicine. He is generally considered the academic leader of the hospitalist movement, the fastest growing specialty in the history of modern medicine. He is also a national leader in the fields of patient safety and healthcare quality. He is editor of AHRQ WebM&M, a case-based patient safety journal on the Web, and AHRQ Patient Safety Network, the leading federal patient safety portal. Together, the sites receive nearly one million unique visits each year. He received one of the 2004 John M. Eisenberg Awards, the nation’s top honor in patient safety and quality. He has been selected as one of the 50 most influential physician-executives in the U.S. by Modern Healthcare magazine for the past eight years, the only academic physician to achieve this distinction; in 2015 he was #1 on the list. He is a former chair of the American Board of Internal Medicine, and has served on the healthcare advisory boards of several companies, including Google. His 2015 book, The Digital Doctor: Hope, Hype, and Harm at the Dawn of Medicine’s Computer Age, was a New York Times science bestseller.


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