If physicians are expected to perform research and publish that research in addition to practicing medicine full-time, then their careers may be on the line if they do not publish. Until recently, many institutions in China also awarded bonuses for publications (article). Additionally, bibliometric indicators of productivity and impact are used in hiring/promotion/tenure decisions worldwide.

In terms of the risk/reward of buying/securing authorship on paper mill products, it is worth noting that very few paper mill products are actually detected, and far fewer still are ever retracted. Thus, reward can be enormous for the client while risk is relatively small.

>Hospital-based clinicians may be particularly vulnerable to publication quotas (34,35,45,46), as their time, training and resources are directed towards patient care as opposed to research (47).