'Indian doctors have moved slightly towards American system for money'

With 60 per cent of its $110 million annual revenues coming from outside the UK, and with a presence in a dozen countries, British Medical Journal (BMJ) is no longer a standalone publisher of scientific books. While the core of its product offering continues to be peer viewed medical research articles, it has diversified into an entity that offers learning modules for continuing medical education (CME) for doctors, best practice guidelines for practicing physicians and bestows clinical excellence awards. On a visit to New Delhi to participate in the BMJ Awards South Asia 2017 ceremony, Patrick Spencer, chief operating officer, BMJ, speaks to Business Today about his company's role as an international information provider and its increasing interest in India. Here are the excerpts

What is so special about BMJ Awards?
We are different from a lot of awards you see because it is meant to be aimed at rewarding and recognising healthcare workers who have done a good job. We have done that in the UK for 10 years now. For this year's award, we had over 2000 entries from all over South Asia. After the initial screening it became 134. Each of them was asked to provide detailed information, which was scrutinised to arrive at a final list of 30 from 10 categories.  One of the category is maternal and child health. Another one is the best primary care team in challenging circumstances. The third award goes to the best non-communicable disease initiative of the year.

Are you moving away from your core area of publishing?
No. We do a whole range of activities in healthcare space. But our core business has always been medical publishing. We do publish core medical research articles. We have a repository of three million articles from more than 60 peer-reviewed journals.

What is the revenue share of your publishing business?
Of the $110 million annual revenues, biggest chunk comes from the subscription business. Since it is very difficult for a company of our size to have people everywhere, we find partners in many other countries with rights to our content. So subscriptions and licensing fees from such arrangements make up 70 per cent of our income. Another 10% must be advertisements and sponsorships from pharmaceutical companies and medical devices companies. The smallest share is from events.

What is the direction in which scientific publishing is moving?
We are seeing our subscription income starting to slow down or flatten off, and an alternative, open access system coming up. The trouble with the open model is that if everything is made open, there is no filter on quality. BMJ's open access model is different. We would reject 95% of the papers we receive either because it is not original research, or because it does not have enough of change than what we know before, or since we think it is biased because it was part of some sponsored research. That is why if an article is published in BMJ, it has a stamp of approval. If you go into a totally open system, everybody will just be publishing everything and you can't tell what good research is. So we are in this interesting juncture where we absolutely need the organisation to do the filtering to see what is good and what is not. And how do you get paid for that?  In the old way, you give it to the publisher; they own it, lock it up and sell it to people. The new way is that the publisher gets paid for the services they do and it can be opened up.

Can you elaborate?
Researchers pay directly to the publisher and that research article is made freely available to anybody in the world. It's turning on its head of the old publishing model. But that provides a one-off income to us. The traditional problem with publishing was that one university will pay to do some research and another university will have to pay BMJ to see that research. If you try to find a research paper online, as you try to open it, you will be asked to pay for it. So as a user of this information, you will always have to pay for it. The other model is rather than the publishing companies have the copyright to that, and charges everybody to see it the publishing company gets paid for doing the job of peer review, checking it and getting it in a good position to publish it.

How significant is India for BMJ?
We have about $2-3 million of income coming from India. It's still relatively small, but growing fast. Like all other businesses, we are also interested in areas of growth and India is one. India's per-capita spend on health is horribly low. So if we stand back and observe, we will realise that the direction India will take now will be to develop it further and further. We want to be present in this growing market.

Are we seeing quality publications from India?
Yes there are. There have always been very good pockets of research, but its low relative to India's potential. It produces a lot, but not always good enough to get published. We want to assist Indian doctors to design the research and report them in such a manner that it will not get rejected.

How do you make money by doing so?
We have a lot of learning resources that help doctors to learn how to do something, to treat a particular condition. We also have resources to help doctors publish their clinical skills. The whole ecosystem of healthcare in India has been low profile for a long time. India can generate lot of rich research findings that can be exported to the rest of the world. Earlier we were creating content in UK - like connection between lung cancer and smoking - and exporting to India, now we want to generate content in India and export it to Europe, which has a huge population of South Asians. We have prepared content on diabetes which tells you how to treat diabetes in Indian population. We are finding that there is lot of interest to that content outside of India because the same people with South Asian heritage live elsewhere. Our business is in two parts. One is journals, where we publish research in specialty areas like cardiology and so on and the other part of business is to create resources to doctors to help them do their job better. It also helps in continuing professional development medical education.

How many doctors have shown interest?
We have seen some states like Delhi and Goa introducing a formalised continuing medical education (CME) for their doctors. The other states are yet to catch up. Meaning, once doctors in these states graduate they are allowed to operate at a level which suits them as individuals and not a level which patients would want them to be at.

Why are doctors hesitant?
Indian doctors have moved slightly towards the American system where you see doctors going into medicine for making money rather than a vocation. They are partly thinking of the patient, and partially thinking of their pockets. If I send them for a test, will I get a couple of dollars as commission? This is all pushing costs up, and it is coming back to hit the patients. In India, patients pay out of pocket for drugs and tests that they don't really need.

How to tackle it?
We have to do it state-by-state. You have to deal with state medical councils to make CMEs mandatory. What is needed is a cultural change. It's something BMJ has been very serious about. Some three years ago, we did a piece about corruption in healthcare. This was written by an Australian doctor who worked in Mussoorie for a year. He lived in India and worked as a doctor, and at the end of his term wrote a piece as an insider to reveal what was wrong with the system and that how doctors were incentivised to give the wrong treatment.