I’ve been reading surveys of physicians and attending focus groups filled with physicians for more than 20 years. If there’s one clear trend, it’s that science is becoming less important in the daily lives of practicing physicians. It seems to me that they are less likely to be aspiring scientists and seem more attuned to merely surviving the daily grind — paperwork, administrative duties, and patients. They don’t even bother to posture about their academic aspirations anymore. Everyone seems to be feeling burned out and hustled.

Physicians have always struck me as the great translators of science into practice — biomedicine in action — so it’s a bit alarming to observe the persistent erosion of their identification with science.

They do still pay attention to the scientific literature, but increasingly through the smaller eyepiece of the major journal brands — the New England Journal of Medicine, JAMA, the Lancet, and maybe one major specialist journal. Beyond this, the impression one gets is that science has become unapproachable for them.

There seem to be three major reasons.

There are the receiver issues — these are the ones mentioned previously, where the receivers of the information are simply too busy, too distracted, or too weary to spend time perusing the latest science in any depth. Underneath these trends are larger trends in medicine, with primary care physicians becoming gatekeepers who mostly refer patients to specialists; specialists who have to focus intensely on their areas of expertise to maintain the quality of care demanded by insurers, so don’t have time to look beyond the specialist literature; hospital purchasing and formulary systems that further limit physician autonomy; and a general lack of incentives beyond continuing education for remaining attuned to the latest findings in the literature.

Then, there are the problems caused by the senders of information. These problems are also familiar to us — too many papers, severe filter failure, untrusted brands, and the rapid churn of the information turnstiles. We are sending too much undifferentiated material to these readers, who have less and less time and inclination to absorb it. Recently, in focus groups that went beyond physicians to include scientists from many biomedical disciplines, this problem was also apparent. In response, it seems readers are shutting out the increasing noise and limiting their world to stronger signals, which carry the stronger brands. Physicians are also looking more at synthesized information solutions (e.g., UpToDate, Medscape) as ways to get a level of science that’s been vetted as practical and close to community standards for care.

Then, there is a fulcrum issue, which is best represented by Google. That is, why read information that is pushed to you when you can Google something that’s right in front of you? There is a workflow dimension to this, certainly, but also a corrosive problem of dependence. It’s good for Google, but not great for science, which often takes reflection, immersion, and inspiration to work. It’s not just a journeyman’s game, with Google as an occasional toolbox. After all, the algorithms at Google may or may not be robust enough to give physicians the best answers.

Perhaps it’s merely a coincidence, but three trends have occurred coincident with the bifurcation of physician practice and physician science, at least as I hypothesize it:

open access (OA) and its emphasis on the article economy

the replacement of personal subscriptions with institutional access

the disappearance of print

Each of these has contributed to an overall gestalt — science has become abstracted away from practitioners. It has disappeared from the tangible world as journals have disappeared from tables, desks, and waiting rooms. It now lives in the cloud, where it is unmanageable except through search engines, maybe. It has disappeared from professional economies, as library budgets have superseded department, group, or individual spending. And it has become a producer-side commodity, something less helpful to readers even as it has become more tractable for authors.

It’s fascinating to watch physicians talk about how science is less and less important to their daily lives. This is going on while we constantly debate how to publish more science. After all, more papers without a paywall after publication should increase interest in science, right?

We tend to forget that water can be fatal in too high a dose. There is “too much” of anything.

We’re so fixated on citations, OA, APCs, embargoes, and all the other ephemera we debate too long and too often that it’s easy to forget the purpose. It’s not to strut our stuff, it’s not show how morally superior one faction is against another, and it’s not to win some sort of Pyrrhic intramural victory. We have readers, and while it’s convenient and even easier to serve authors, ultimately we serve readers. Even our authors agree on that fact.

Reaching readers is not a passive act, with the only requirement turning the “access” switch to “on.” After all, everything has been accessible for a long time — it only required an economic exchange at the point of sale, rather than at the point of production. The notion of a point of sale may be crucial, as it kept the customer in sight.

It’s actually quite a bit more difficult these days to be a reader. There are fewer sources of continuity, more competing flashes and fewer steady beams. It’s no wonder physicians are retreating from the action into trusted brands that provide them with steady and reliable editorial experiences.

Reader-friendly innovations also seem to be slowing down as the bigger and better-funded publishing companies begin to orient themselves toward OA, which provides a source of ready money with little upfront capital expenditure or need to build a sufficient reading audience. Why pursue the longer game of creating value for readers when you can pursue a lower-cost, quick-return game with OA?

Focusing on peer-review purely as a type of validation rather than as an activity that also helps determine importance and relevance is another shift away from readers. Not only does the review itself likely suffer from some basic problem (if you don’t know who you’re reviewing for, how can you review a work properly?), but the output is not tailored for an increasingly specialized scientific community, making it both harder to find but also less likely to be picked up and used.

I’ve been criticized in the past for asserting that making something available online doesn’t mean it matters, especially to the average taxpayer — most of what is published in scientific papers is orders of magnitude more complicated and nuanced than material most taxpayers can understand, nevermind implement. Reading levels are wrong, for a starter, but even scientists in one discipline can’t understand much of the science in another, so the problem of utility and relevance is complex. Ellen Collins, a social researcher, recently wrote about the limits of utility in public access in a charming blog post after having her science discussed in the Guardian:

. . . just because we make something open doesn’t mean people will actually read it. . . . I believe in open access. I think it is a good thing that the general public should be able to see the results of scientific research. But I think we also need to acknowledge that making this complicated, messy, highly technical content open to people who don’t have the expertise — or perhaps even the inclination — to explore it properly, is a risk. And that if we are serious about openness we need to do more to help people find, read, understand and critique the original research outputs.

Jeff Bezos, in an essay announcing his acquisition of the Washington Post, hit on some of these themes, informed by his ferocious focus on the customer:

Our touchstone will be readers, understanding what they care about – government, local leaders, restaurant openings, scout troops, businesses, charities, governors, sports – and working backwards from there.

From Amazon to Apple to Google to Virgin to Flipboard, the reasons to pay attention to the actual consumer are legion. But the disciplines to be this customer-centric are often a bit alien to publishers, from reader surveys to focus groups to usability studies to observational studies to interviews. Many publishers work hard on author surveys, but little on reader surveys, or have library advisory boards but no reader advisory boards.

As we ourselves orient further back toward the producers, the customer becomes secondary. We devote far more of our bandwidth these days to serving authors, funders, and librarians than serving readers. Yes, reading is just a mode and not a person, but it’s the mode that matters the most, perhaps. Authors, funders, and librarians serve readers — we should all be aligned on this. But the move toward OA seems to be silvering the glass rather than making it clearer. We’re ending up looking at ourselves more than we are looking out for our customers.

We’re here to put science in the hands of people who can use it. This is not accomplished by the passive approach of “access.” It requires active marketing, delivery, and brand-building. Unfortunately, from what I’ve seen over the past two decades, we are losing track of the actual customers — the readers, the users, the physicians, the scientists.

If we sever that connection — based on utility, value, and meaning — we’ll certainly have lost everything.