Books, journals, and UpToDate for less than retail

Until recently, most physicians consulted the kind of medical journals that stand bound in hundred-year chunks on the towering metal shelves of medical libraries. Those journals not only make for meaty browsing, with their retro advertisements and dated syntax, but also hold a wealth of valuable medical information, much of which remains unarchived on electronic media. Still, going to such shelves to look up a journal article is like knitting your own socks: it would be nice, but nobody has time. We find journal articles online instead.

Most of the journals I've needed to consult in my medical career are available online by subscription. Already pricy as physical copies, the journals can be grievously expensive in their electronic forms, even with tiered pricing. In some cases, caregivers in poor countries get a price break. The New England Journal of Medicine, for example, allows free access to URLs from 119 low-income countries.

The WHO has seen to it that many such journals are accessible to low-resource clinicians who have the bandwidth. HINARI is a WHO project to allow some institutions* in developing countries to read medical journals in the medical literature either for free or for $1000/year, depending on level of poverty of their countries. It was started in 2001 with six publishers: Blackwell, Elsevier Science, Harcourt Worldwide STM Group, Springer Verlag (Bertelsmann), John Wiley, and Wolters Kluwer International Health & Science. The site comes in seven languages, and the journals in 22. So far there are 6,458 journals thus accessible.

Despite Wolters' involvement with HINARI, one resource I haven't found on either HINARI or Free Medical Journals is UpToDate, Wolters' immense evidence-based and physician-authored article service that is the first place many American doctors turn with questions on the job. It has plenty of international subscribers, but they are charged full price. I filled out their subscription form as a theoretical internal medicine physician from the United States. The cheapest option is one for trainees at $195 a year, plus $15 for shipping and handling. A standalone subscription is $1,495. I also filled it out as the same physician from Botswana--same prices, except higher S&H.

That looks to be changing, though. Though their home page and subscription form don't signal this, UpToDate recently rolled out a donations program that allows institutions in poor areas of the US and poor countries to apply for "a limited number" of free subscriptions. It's administered through the Global Health Delivery Project, a brainchild of Paul Farmer, Jim Kim, and Michael Porter (if you don't know who these guys are, read this first). Institutions can apply to a January or May 2010 deadline for the first round of grants. It's not clear how many grants will be awarded or how applicants are judged, although an UpToDate spokeswoman has promised (12/3) to get back to me on this. In any case, it would seem to be a welcome development for low-resource medicine.

* A small-town clinic doesn't quality under its rules, which state that access "applies only to bona fide academic and research institutions."

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Other links to free medical information online:

* The WHO Formulary (pdf).
* Pubmed.gov allows the searcher to specify that searches return only free fulltext hits.

* HighWire's list of free full-text journals, some offering only older content for free.

* Excellent list of online resources compiled by a nursing informatics specialist. The most helpful links are toward the end of the page.

* FreeBooks4Doctors and FreeMedicalJournals' eponymous offerings are apparently accessed by thousands of readers around the world, though some of its journals are only free after a one-year paid subscription. This and the preceding site are maintained by the efforts of a man named Bernd Sebastian Kamps, who also offers a prize to the best medical textbook created to be freely available online. Good idea--there is nothing like a contest to maximally leverage effort.