Letters to the Editor  |   December 2008
Mayo Clinic Proceedings`Relationship With Osteopathic Physicians Misrepresented
Author Affiliations
  • William L. Lanier, MD
    Mayo Clinic Proceedings, Professor of Anesthesiology, Mayo Clinic College of Medicine, Rochester, Minn
    Editor in Chief
Article Information
Medical Education / Pediatrics / Pulmonary Disorders / Graduate Medical Education
Letters to the Editor   |   December 2008
Mayo Clinic Proceedings`Relationship With Osteopathic Physicians Misrepresented
The Journal of the American Osteopathic Association, December 2008, Vol. 108, 677-717. doi:
The Journal of the American Osteopathic Association, December 2008, Vol. 108, 677-717. doi:
To the Editor: Earlier this year, Jason M. Golbin, DO, who was finishing a residency in pulmonary critical care medicine at the Mayo Graduate School of Medicine in Rochester, Minn, brought to my attention a letter to the editor by Linda P. Ha, DO,1 that appeared in the February issue of JAOA—The Journal of the American Osteopathic Association. In this correspondence, Dr Ha made it appear as if the internal medicine journal Mayo Clinic Proceedings—for which I serve as editor in chief—and the journal's parent organization, Mayo Clinic, may be insensitive to the identity and professional needs of osteopathic physicians in the United States. 
Dr Golbin's note to me contained the following statement: “I was surprised by [Dr Ha's] letter...given my perception that at Mayo, the initials after your name do not matter, for we are all interested in the best possible care for our patients.” 
The perception of Dr Golbin is correct. At Mayo Clinic, no differentiation is made between osteopathic and allopathic physicians. In recent years in my own home department at the clinic, the Department of Anesthesiology, an osteopathic physician was recognized by residents as “Teacher of the Decade.” Further more, the vice chairman of this department for many years was an osteopathic physician, and one of our faculty members became the only DO so far to attain the presidency of the American Society of Anesthesiologists (a position that requires not only immense talents but also considerable support from the department). In addition, osteopathic physicians frequently contribute to Mayo Clinic Proceedings as authors and reviewers, and we make no effort to distinguish between DOs and MDs in our day-to-day activities. 
It is true that Mayo Clinic Proceedings is routinely sent to MD internists but not DO internists for reasons that I will discuss later. Appropriately, several osteopathic physicians have individually contacted me to request complimentary subscriptions, and I have responded immediately to those requests or had someone respond on my behalf. However, given that it is possible for readers to directly contact any of the 30 members of Mayo Clinic Proceedings' editorial board, its office staff, and its publisher, I cannot speak for all parties whom Dr Ha or others may have approached. If one of our representatives or I responded to Dr Ha's initial subscription request but did not respond to her second letter (as her comments in the JAOA1 suggest), I suspect that we assumed that everything we could have said about her concerns had already been said. Indeed, considering the thousands upon thousands of exchanges that we have with authors, reviewers, and subscribers each year, it is possible that we construe some communications to have reached their logical completion when the parties on the other end differ. 
Despite such occasional misunderstandings, I believe it is fair to enlighten the JAOA's readers on how Mayo Clinic Proceedings—and many other medical journals—handle complimentary and reduced-rate subscriptions. (I shudder at using the word “free” because there is nothing at all free about these practices from the journals' point of view.) 
Mayo Clinic Proceedings is an independent financial entity with an annual budget of millions of dollars. Thus, it is imperative that we codify those readers who should and should not receive complimentary subscriptions. In doing so, we rely on FOCUS and Media-Chek/APEX studies generated by The Nielsen Company,2 a commercial research firm based in New York, NY. These studies of medical publications help define our audience and quantify the characteristics of our readership within that audience. (In a sense, FOCUS and Media-Chek/APEX studies assess journal readership much like the more widely know Nielsen ratings assess television viewership.) 
It is the intent of Mayo Clinic Proceedings to saturate coverage of readers within general internal medicine, as well as within select internal medicine subspecialties. If our journal is highly read by physicians within this demographic, FOCUS and Media-Chek/APEX readership surveys will reflect that fact. In turn, advertisers will be made aware of our impressive readership within this demographic, and they will be more likely to include advertisements in our journal for products targeted at the general internists and medical subspecialists we reach. As a consequence, for each dollar we spend on complimentary and reduced-rate subscriptions in an attempt to better reach our target audience (as quantified by FOCUS and Media-Chek/APEX), we hope to regain a fraction of that dollar as a result of downstream advertising sales. 
In the survey system used by The Nielsen Company, osteopathic physicians have for years been categorized in two audiences: multispecialty and primary care. As The Nielsen Company has kept these two audiences separate from the general internal medicine audience served by our journal, any complimentary subscriptions of Mayo Clinic Proceedings that are provided to osteopathic physicians would not register at all in the business calculus that we use to maintain our fiscal viability—any more than would complimentary subscriptions to allopathic or osteopathic psychiatrists, pediatricians, or obstetricians. As more than 4000 osteopathic physicians are affected by this policy, the sum of money involved in providing complimentary subscriptions to them would be considerable. 
Although several osteopathic physicians have individually contacted Mayo Clinic Proceedings about these issues (as confirmed in Dr Ha's letter1), it was not until last year that an organized body representing DOs approached us to explore a systematic solution. The first official contact that we can document from the American Osteopathic Association (AOA) occurred in the summer of 2007. In a letter of reply from our publisher dated August 31, 2007, the following information was shared: 

Advertisers evaluate journals using the syndicated reader research conducted by PERQ/HCI, who study DOs as part of the multi-specialty audience, and only differentiate them as primary care or multi-specialty. [Editor's note: PERQ/HCI now operates under the name The Nielsen Company and is responsible for conducting the biannual FOCUS and Media-Chek/APEX surveys.] They often view DOs as a separate specialty. While I have questioned this flaw in the research, PERQ/HCI does not have any plans to change their methodology at this time. We agree that it is less than ideal that our advertisers categorize DOs this way and we recognize the variety of specialty areas in which they practice, as well as the importance of their role in health care. However, the bottom line is that...we would not get credit for adding internal medicine DOs to our circulation.

To emphasize, the internal medicine audiences surveyed by FOCUS and Media-Chek/APEX have for many years consisted exclusively of MDs. Thus, to reach our targeted physicians, we have obtained our mailing list only from the American Medical Association (AMA)—a list that is based on that organization's categorical registry of MD specialists and subspecialists. 
Our publisher's August 2007 letter to the AOA recommended several methods for remediating the problem of obtaining print subscriptions for DOs, including a proposal for Mayo Clinic Proceedings and the AOA to work together to make Mayo Clinic Proceedings available to DOs at a reduced rate. The letter also suggested that the AOA convey to its members that it was responsible for negotiating this favorable rate. Our publisher closed this portion of the letter with the statement, “I think you will agree that this is a generous offer.” We still feel this way about the offer. 
We were also responsible, in part, for arranging an exchange between AOA representatives and a senior representative of The Nielsen Company, who explained the company's position on DO classification and its impact on journal economics. Internal memos at our office from September 14, 2007, suggest that this meeting went well. According to our communications documenting those interactions, AOA representatives seemed satisfied with the Nielsen representative's explanation. 
On the basis of these exchanges, I would argue that Mayo Clinic Proceedings has in no way been dismissive of the needs and desires of US osteopathic physicians to receive our journal. Frankly, we are flattered by the interest in our journal shown by individual DOs and the AOA. However, we believe that in her JAOA letter,1 Dr Ha misrepresented the facts. The miscommunication was not between Mayo Clinic Proceedings and osteopathic physicians (either individually or collectively) but instead among osteopathic physicians, researchers who analyze DO reading patterns, and the advertisers that market products to the osteopathic medical profession. In the world of market researchers (whether appropriately or not), DOs have historically been categorized as multi specialty physicians and primary care physicians—categories that are distinct from Mayo Clinic Proceedings' mission and target audience (ie, general internists and internal medicine subspecialists). 
Subsequent to our September 2007 memo, The Nielsen Company informed the publisher of Mayo Clinic Proceedings (written communication, November 2007) that the summer 2008 FOCUS and Media-Chek/APEX surveys would report data on non–primary care osteopathic specialists along with MDs from the same non–primary care specialties. While general internists are not covered by this change, internal medicine subspecialists are. Mayo Clinic Proceedings would like to think that our actions facilitating communication between the AOA and The Nielsen Company had some bearing on the latter's homage to osteopathic specialists and subspecialists. I hope that this new readership research effort will help give DOs the credit and visibility they deserve. 
Since our August 2007 letter to the AOA offering to provide subscriptions to DOs, we have considered the ball to be in the AOA's court. Mayo Clinic Proceedings will gladly engage in a formal, large-scale relationship with the osteopathic medical profession if the AOA accepts our generous offer to provide print copies of our journal to osteopathic physicians at a reduced rate. 
In the mean time, Mayo Clinic Proceedings will provide free electronic subscriptions to our journal if the AOA will provide us with the names of osteopathic physicians who are within the appropriate practice demographics (ie, those involved in the practice of general internal medicine and the major medical subspecialties). Although we would very much like to take an even bolder step in this direction, that is not possible at this time given the considerable recession in advertising revenues and the overall tenuous finances that are currently affecting leading medical journals. 
In summary, we at Mayo Clinic Proceedings would very much enjoy expanding our relationship with osteopathic physicians whose clinical practices place them within our target demographic. 
Ha L. Ignorance in high places [letter]. J Am Osteopath Assoc. 2008;108:84-85 Available at: Accessed November 20, 2008.
Product information. The Nielsen Company's PERQ/HCI Web site. Available at: Accessed November 20, 2008.