Increasing Importance and Costs Associated With Publishing for Dermatology Residency Applicants

The financial costs associated with publishing in academic journals have steadily risen in recent years, reflected by higher publishing fees and the emergence of open access (OA) publishing models. Research remains an essential part of academia and has special significance for residency applicants. Due to recent changes in some objective measures used to rank residency applicants, such as abandoning numerical United States Medical Licensing Examination (USMLE) Step 1 scores and transitioning pre-clinical grades to Pass/Fail, other objective measures have gained significance: in particular, the quality and quantity of research activities including manuscripts, abstracts, and presentations have become more important in residency applications. This has led to a significant increase in the reported number of research experiences and publications to more competitive specialties, including dermatology. Our study analyzes the current financial landscape of publishing in the field of dermatology and the financial burden placed on applicants as well as programs to meet the expected number of research experiences in order to successfully match into a dermatology residency. Through a comprehensive examination of 85 dermatology-based academic journals, we assess the costs and differences of publishing in OA and hybrid OA journals while also exploring potential avenues for mitigating the financial burden of publishing. Our findings indicate that while cost-effective options exist, the financial burden of article processing charges remains substantial.


Introduction
Dermatology remains one of the more competitive specialties for residency applicants to match into [1].In addition to top percentile standardized test scores in the United States Medical Licensing Exam (USMLE) Step 1 and 2 and the National Board of Medical Examiners (NBME) Subject Exams/Shelf Exams, applicants must display a longitudinal interest in dermatology through avenues such as volunteer experiences, shadowing, leadership positions, and research publications [1].With the transition of the USMLE Step 1 exam to Pass/Fail only, along with many medical schools changing pre-clinical grades to a Pass/Fail scoring system and the cancellation of the USMLE Step 2 Clinical Skills exam in the last five years, medical students and residency programs alike have shifted their focus toward other areas of the application to distinguish applicants in highly competitive fields such as dermatology.
As objective measures previously used to stratify applicants are abandoned, others have become increasingly employed; in particular, research experiences and meaningful publications have become more important in residency applications.However, this increased emphasis on research is complicated by the significant financial burden associated with publishing as well as varying institutional access to research opportunities.The introduction and widespread use of open access (OA) and article publishing charges (APC) have placed an undue financial burden on the authors, rather than the readers, to cover the cost of publication.Currently, most journals either employ an OA-only model in which all articles that are published require an APC and are immediately freely accessible, or a hybrid OA option.Hybrid OA journals offer two options for authors: green and gold.The green OA option does not charge an APC and is free for authors to publish but requires a subscription to the journal to read the article.The gold OA option requires the authors to pay an APC and the article is immediately and freely accessible to the public upon publication, similar to the OAonly model [2].This study aims to explore the different publication options and investigate the impact of financial burdens on dermatology residency applicants associated with publishing research articles.

Materials And Methods
The metrics of dermatology-focused academic journals including publishing model and costs were analyzed in order to determine how they can affect medical students' research activities and ultimately play a role in whether an applicant successfully matches to a dermatology residency program.We performed a systematic search of the directory of open access journals (DOAJ) and SCImago Journal Rank (SJR) list using the keyword "dermatology" to identify the relevant journals.The inclusion criteria were dermatology-based journals that accept English manuscripts, publicly display an APC on their website, and have an SJR and H index.The exclusion criteria for this study were journals that do not primarily publish articles in English and those that  We additionally gathered data on which qualifying journals were indexed on PubMed by using the National Library of Medicine catalog [3].
SJR and H index data, both commonly used numeric measurements of journal prestige, were compiled on July 11, 2023, from the SJR database [4].SJR is calculated by taking the weighted number of citations of a journal in a given year to citable publications published in the journal within the three preceding years, divided by the total number of citable publications published in the journal within the three preceding years.
In regards to quartile, the top 25% of calculated SJR values are placed in quartile 1, the next 25% of calculated SJR values are placed in quartile 2, and so forth.H index is calculated by finding the maximum value of h given by a journal that has published at least h papers that have been cited at least h times [4].A higher H index signifies that a journal (or individual author) has had a greater scholarly output that has been cited by other researchers; it can be used to compare publications to citations.We additionally identified the APCs for each journal on their individual websites.If a journal did not charge an APC, the APC for that journal was set at $0 for the purposes of our analysis.All APCs listed in currencies other than USD were converted to USD on July 11, 2023.
Journal metrics were analyzed using Microsoft Excel.We calculated the average APC, SJR, and H index for OA journals, hybrid journals, and all journals included in the study.Two-sample t-tests were used to compare the mean APC, SJR, and H index between OA and hybrid OA journals.Linear regression was used to calculate the correlation between APC and SJR.

Results
Our study included a total of 85 journals, with 45 classified as OA journals and 40 as hybrid OA journals.APCs for these journals varied widely (ranging from $0 to $6,850) with 19 journals not charging an APC.The combined average APC was $2,290.64 while the average H Index was 59.75, and the average SJR was 0.622.The analysis of APCs compared to H Index and SJR is shown in Figures 1, 2.  An analysis of OA and hybrid OA journals separately yielded a significant difference in both publication quality and costs.The 45 OA journals included in our dataset showed an average APC of $1,360.27,an average H Index of 32.27, and an average SJR of 0.452, with 15 open-access journals not charging an APC.The analysis of the 40 hybrid OA journals revealed an average APC of $3337.30,an average H Index of 90.68, and an average SJR of 0.813, with four hybrid OA journals not charging an APC (Table 2).Two-sample t-tests confirmed that the mean APC, SJR, and H index were all statistically different between OA and hybrid OA journals (P < 0.001).There was no significant positive or negative correlation found between APC and manuscript processing time or time from submission to first decision.

Discussion
As the academic publishing landscape continues to evolve, the financial burden on residency applicants and programs continues to increase.If recent trends continue, preparing students for a successful match in fields dependent on high levels of scholarly activity such as dermatology can become increasingly expensive and difficult.According to 2022 National Resident Matching Program (NRMP) statistics, successfully matched applicants had an average of 20.9 publications, presentations, and abstracts and 7.2 research experiences [1].These numbers are expected to rise as more students focus on producing publications to compensate for the absence of a numerical Step 1 score.
In addition to the quantity of applicants' publications, the quality of those publications also plays a role.Publications in high-quality journals carry more weight in residency applications compared to those in lower-quality, pay-to-publish, or predatory journals.However, lower-ranked journals may be easier to publish in, thus attracting submissions from applicants who are actively trying to increase the number of research activities they have before submitting their residency application.One previous study showed that from 2007-2018, the number of publications per applicant in lower-impact journals increased four times faster than the number of publications in higher-impact journals [5].Additionally, this number of publications may be inflated due to the Electronic Residency Application Service (ERAS) policy of allowing students to add "in progress" or "submitted" publications to their application [5].
Although publishing in highly ranked dermatology journals is more impactful for residency applications, it is also more expensive: our analysis revealed a statistically significant positive correlation between SJR and APC, indicating that publishing in higher-quality journals is both more challenging and more costly for programs.The average APC in this dermatology journal review was $2290.64.The financial burden may continue to increase as the number of publications necessary for a successful dermatology match continues to increase, and as more journals continue to shift to an OA-only policy.In institutions where research access and funding are limited, accommodating the interests of students interested in dermatology may be financially prohibitive and impractical.However, when students do publish in OA journals, their scholarly work may reach a wider audience: articles in hybrid journals generate 1.6 times more citations and four times more downloads than their counterparts in subscription-based journals [6].
Smaller academic and community programs are disproportionately impacted by trends in scholarly activity compared to larger institutions with more financial resources and more robust research infrastructure.The widening gap in publishing budgets and research access makes it increasingly difficult for applicants from smaller or community programs to distinguish themselves and successfully match to competitive specialties when compared to their peers in larger, well-funded programs.Attending a highly ranked (top 25) medical school also tended to correlate with a higher quantity and quality of peer-reviewed publications [5,7].As other objective measures are abandoned, otherwise capable applicants may be overlooked for lacking the number and quality of research activities expected.Aside from financial resources at a student's institution and school ranking, previously published studies show varying results on other demographic factors of applicants such as sex and geographic location and whether they yield increased or decreased number of publications, with no clear consensus being reached [6,7].
Students lacking in research experience may elect to complete a research year while in medical school or following graduation to increase their research experiences and their chances of a successful match.Recent trends have shown that program directors of dermatology residency programs have given a demonstrated interest and involvement in scholarly activity a high score in regards to importance for residency applications [7].However, research years are no guarantee of a successful match and are not without pitfalls.Often, research years will require relocation and can carry significant opportunity costs as well as other quotidian burdens, interrupting student loans, health insurance, and other benefits provided to medical students [8].Though applicants who take a gap year for research have been shown to have up to double the amount of research projects on their residency applications, this does not always translate to a successful match [9].Research years remain an untenable proposition to those from socioeconomic backgrounds that may not be able to bear the financial burden of relocation, and for whom the opportunity cost of passing on a year's income/training without a guarantee of a successful match is too high.This further contributes to the inequity present within the medical field and undermines the effort for more equitable distribution of healthcare resources, including residency spots, to those from underrepresented socioeconomic backgrounds.
Despite the rising costs, some affordable publication options still exist.We identified several OA journals in our dataset that do not charge an APC for publication.However, only one of these journals falls within the top quartile of journals according to SJR and only four are within the top 50% of journals.Publishing green OA in hybrid journals is another affordable option for authors, although it may reduce the article's impact compared to gold OA; nonetheless, publishing in these journals remains valuable for authors' residency applications.Though hybrid OA journals offer a financially friendly publication option, the transition to fully OA publishing is becoming more common among journals.One study analyzing orthopedic journals showed that the number of journals exclusively publishing OA articles has increased by more than 100% from 2012 to 2022 [10].A similar trend may be seen in dermatology.As more hybrid OA journals switch to fully OA, costeffective publication avenues will decrease.
The limitations of this study include disclosed and undisclosed discounts offered by journals to certain institutions or via preferred author programs, which we were unable to assess in our analysis.Additionally, this study is limited by the exclusion of some dermatology journals that did not meet the criteria.Furthermore, our study does not consider the difficulty of getting a manuscript accepted as part of our analysis.Future studies regarding this topic should focus on programs' budgets to support student-driven scholarly activity and how increasing publication costs affect them.Additionally, more research can be done on the impact of high-quality journals on application competitiveness.Finally, investigating the difference in article impact between green and gold OA publications can provide valuable insight.

Conclusions
Scholarly activity is a vital portion of any candidate's application for dermatology residency.However, rising costs can serve as a barrier to publication.This study highlights the financial burden resulting from the shift toward OA publication models.While cost-effective options still exist, APCs place significant strain on authors and their sponsoring programs, and as the illustrated trends continue, this financial burden will only increase.As the pursuit of research publications remains pivotal for success in dermatology residency applications, it is essential for medical schools, dermatology programs, and journals to address these escalating financial challenges to ensure equitable opportunities for aspiring dermatologists.

FIGURE 1 :
FIGURE 1: Comparison of Journal SJR to Journal APC SJR: SCImago journal rank; APC: article processing charges

FIGURE 2 :
FIGURE 2: Comparison of Journal H Index to Journal APC APC: Article processing charges

TABLE 1 : Dermatology Journal Metrics
[2,3]t of all journals included analyzed with metrics including their associated APCs (Article processing charge), H indices, SJRs (SCImago journal rank), and quartiles[2,3].JDDG: Journal der Deutschen Dermatologischen Gesellschaft; JMIR: Journal of Medical Internet Research; JEADV: Journal of the European Academy of Dermatology and Venereology