 |
© CartoonStock.com |
There was an intriguing piece in the New
England Journal of Medicine this week about a commonly used screening test
that indicates if someone is likely to have dementia. The Mini Mental State
Examination (MMSE) is widely used throughout the world because it is quick and
easy to administer. The test is very simple: you need no equipment, and the eleven
items, involving questions to test orientation (e.g. “Where are we?”) and
language (e.g. “What is this?” while showing the patient a wristwatch) are
reproduced at the end of the original
article about the MMSE, which was published in 1975.
The problem is that now the authors have taken steps to
license the test, so that it has to be purchased from Psychological Assessment
Resources. The cost is modest, $1.23 per test, but nevertheless more than the
cost of photocopying one side of paper, which is what people have been doing
for years. And of course, if people have to use only officially purchased
copies of MMSE there are the additional costs of raising purchase orders,
postage, storing packs of forms, and so on.
I’ve got a particular interest in this story, as I have
published psychological tests, both off my own bat, and through a test
publishing company. I started out in the late 1970s, when I developed a test of
children’s comprehension called the Test for Reception of Grammar (TROG). This
was more complicated than MMSE in two important respects. It involved lots of brightly
coloured pictures as well as a record form, and in order to decide if a child
had comprehension problems, I needed to establish how well typical children
performed at different ages. The latter process, known as test standardisation,
is not a trivial task, because you have to test lots of children to get a good
estimate of the range of scores as well as the average score at different ages.
This early work was done as part of a study funded by the Medical Research
Council (MRC), but I assumed that, if the project worked out, we’d need a test
publisher, and so I contacted one. The project involved two big costs. First
there was the cost of my time and effort in devising the test, finding reliable
people to test hundreds of children nationwide, analyse the results and write
the manual. The other cost was printing colour test booklets. I had assumed
that the test publisher would be willing to cover this, but they weren’t. They
suggested that the MRC should find another several thousand pounds to cover
printing. Now this made me cross. The publisher would get for free a fully
standardised test that they could sell, no doubt at vast profit, but they
wanted someone else to foot the bill for production costs. MRC were actually
making quite positive noises about finding the money, but I was irritated enough
to explore other options. I found a local printer and learned about the arcane
world of different colour separation processes, and came away with a reasonable
quote. I also discovered something quite interesting. The costs were all in the
initial process of creating plates: the actual printing costs were trivial.
This meant that it cost no more to print 1,000 picture books than the 100
copies I needed. And the costs of printing record forms were trivial. I
returned to MRC and suggested we left the publisher out of the equation, and
they agreed. All proceeded very smoothly, but once the standardisation was
completed, I had a problem. There were 900 unused copies of the picture book. I
discussed with MRC what we should do. They suggested I could give them away,
but this would mean the test would become obsolete as soon as all the copies
were used up. In the end, we reached an agreement that I could sell the test in
a kind of cottage industry, and share any profits with MRC. And so I did for
about the next 15 years. I didn’t bother to copyright the test because it was
cheaper to buy it from me than to photocopy it. Nevertheless, I made a nice
profit, and took considerable pleasure in telling the publisher to piss off
some years later when they approached me expressing interest in TROG.
My next foray into test publishing was with a four-page
questionnaire, the Children’s Communication Checklist (CCC). As with TROG, I
hadn’t set out to devise an assessment: it came about because there wasn’t
anything out there that did what I wanted, so I had to make my own instrument.
I published a paper
on the CCC in 1998, and listed all the items in an Appendix. I had a
problem, though. I was getting busier all the time. For some years I had been
paying graduate students to look after TROG sales: the weekly trip to the post
office with heavy parcels had become too much of a chore. And every time I
moved house, there was the question of what to do with the stock: boxes of
picture books and record forms. I also realised that TROG was getting out of
date - it’s well recognised that tests need restandardising every ten years or
so. I also wanted to develop a test of narrative language. And the CCC was far from perfect and needed
revamping and standardising. So I took the big step: I contacted a test
publisher. A different one from before. To cut a long story short, they put
money into the standardisation, covered production costs, and offered highly
professional editorial support. There are now three of my tests in their
catalogue.
The upside for me? The tests are actually marketed, so sales
are massive compared with my cottage industry activities. And I no longer have
to keep a cellar full of cardboard boxes of stock, or concern myself with
organising printing and despatching tests, or dealing with complaints from
someone whose finger was cut by an injudiciously placed staple. There is a
downside, though. The tests are far more expensive. Having done the publishing
myself, I know a little secret of the test publishing business: they don’t make
their profits from actual test materials such as coloured picture books or IQ
test kit. The profits are all in the record forms. These cost peanuts to
produce and are sold at a mind-boggling mark-up.
I went into the deal with the publisher with my eyes open.
They are a business and I knew they’d make profit from my academic work - just
as journal publishers do. I reckon they’ve done more to deserve that profit
than most journal publishers, as they put money into test development. That
involved taking a gamble that the tests would sell. I have benefited from
having a large professional organisation promoting my work, and I do get
royalties on the tests. I recycle these back to a relevant charity, and there’s
something pleasing about profits from testing children’s language being
ploughed back into helping children with language problems.
But my publisher’s situation is very very different from the
situation with MMSE. The only people who could plausibly argue they deserve to
make money from the test are its authors: the publisher has put no money into
development of the test and taken no risks. The authors appear to be claiming
that the test items are their intellectual property, and that anyone who
attempts to develop a similar test is infringing their copyright. But where did
the MMSE items come from? A quick read of the introduction to the 1975 paper
gives an answer. Most of them are based a longer assessment described in a 1971 article by Withers
and Hinton. It would seem that the main contribution of Folstein et
al was to shorten an existing test. I wonder if the British Journal of
Psychiatry should go after them for copyright infringement?
Newman, J., & Feldman, R. (2011). Copyright and Open Access at the Bedside New England Journal of Medicine, 365 (26), 2447-2449 DOI: 10.1056/NEJMp1110652
P.S. Another post that includes some information on how MMSE was developed.
You can read more by scrolling down to "The Mini Exam with Maximal Staying Power" on this site from 2007.
