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Editorial

Psychother Psychosom 2001;70:283287

Which Are the Leading Countries in

Clinical Medicine Research?

A Citation Analysis (19811998)

Giovanni A. Fava Fedra Ottolini Nicoletta Sonino

Department of Psychiatry, State University of New York at Buffalo, Buffalo, N.Y., USA

G.A. Fava, MDDipartimento di PsicologiaViale Berti Pichat 5, I40127 Bologna (Italy)Tel. +39 051 243 200, Fax +39 51 243 086E-Mail fava@psibo.unibo.it

ABCFax +41 61 306 12 34E-Mail karger@karger.chwww.karger.com

2001 S. Karger AG, Basel00333190/01/07060283$17.50/0

Accessible online at:www.karger.com/journals/pps

The Institute for Scientific Information (ISI) has devel-oped a database of publication and citation statistics theNational Science Indicators on Diskette (NSIOD) thatreflects scientific research performance of 100 nationsduring the years 19811998. The database includes publi-cations and citations taken from the peer-reviewed jour-nals indexed by ISI. It is designed to analyze the state ofresearch of different countries in different fields. Numberof papers published by year, their fate (citations) and thenumber of citations per paper published (impact) can beanalyzed.

A citation analysis concerned with the overall field ofclinical medicine during 19811994 was published in1996 [1]. It disclosed a clear-cut superiority of the US, UKand Canada. The aim of this paper was to provide anupdated (19811998) and more detailed survey of thefield.

The NSIOD database (19811998) of the ISI was ana-lyzed. Fifteen fields which were derived from CurrentContents/Clinical Medicinewere selected for the analysis:

general and internal medicine; cardiovascular and respi-ratory system; gastroenterology; hematology; endocrinol-ogy, metabolism and nutrition; rheumatology; environ-mental and social medicine; clinical immunology andinfectious disease; anesthesia and intensive care; surgery;oncology; reproductive medicine; radiology, nuclear med-icine and imaging; clinical psychology and psychiatry,and pediatrics. Only 2 fields are reported in detail here.One is general and internal medicine, which includes the

papers published in journals such as theLancet and TheNew England Journal of Medicine. This is the broadestfield. The other is clinical psychology and psychiatry. Itincludes a selective number of high quality journals with aclinical focus, compared to the general fields of psycholo-gy and psychiatry, which have been object of previouspublications [2, 3]. It is thus most suited for analyzing thespecific contributions of clinical psychology and psychia-try within clinical medicine. For each field the top 20countries for number of papers in the 18-year period wereextracted. Subsequently, their impact (number of cita-tions divided by number of papers) was calculated. Final-ly, their most recent 5-year impact (19941998) was com-pared with their earliest one (19811985).

Table 1 provides the data concerning the field of gener-al and internal medicine. The US and the UK, followedby Germany, France and Canada are the top countries fornumber of papers. However, Swedish papers have thehighest impact, and the UK is preceded by the Nether-lands and Denmark. Table 2 illustrates the impressive

rise of the Netherlands and Scandinavian countries com-pared to the US and the UK. It is Italy, however, whichdisplays the greatest change in impact. Italy, the Nether-lands, Sweden and Belgium have a higher 19941998impact than the US. Figure 1 compares the citation im-pacts of world regions (US, European Union, Australiaand Asia, and Latin America). The American supremacyis not challenged by the European growth.

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Table 1. Impact, citations and papers in General and Internal Medi-cine of the top 20 countries for number of papers (19811998)

No. Country Impact Citations Papers

Sweden 21.17 81,722 3,8602 US 20.83 2,015,339 96,7333 Netherlands 20.26 80,119 3,9544 Denmark 16.71 52,182 3,1235 UK 15.26 601,286 39,4116 Belgium 14.04 34,839 2,4817 Italy 12.53 61,332 4,8938 Canada 12.45 155,665 12,5079 Australia 10.33 91,193 8,825

10 Switzerland 8.40 63,230 7,52711 New Zealand 8.06 28,077 3,48312 Japan 7.35 32,475 4,41713 Israel 6.73 29,570 4,39314 France 5.11 112,902 22,10115 Germany 4.62 105,810 22,88716 South Africa 4.43 26,294 5,93817 Ireland 4.32 12,088 2,79518 Austria 3.97 14,962 3,77119 Spain 2.72 26,419 9,69820 China 1.75 6,315 3,609

Table 2. Top 20 countries for number of papers in general and inter-nal medicine in a cumulative 18-year period (19811998) ranked bychange in impact for 19941998 compared to 19811985

No. Country Impact8185

Impact9498

Change in impact8185 vs. 9498

Italy 1.26 11.90 10.642 Netherlands 3.33 11.01 7.683 Sweden 3.82 11.14 7.324 Belgium 2.82 9.95 7.135 Canada 2.05 7.83 5.786 Denmark 3.20 6.76 3.567 France 0.95 4.23 3.288 Germany 1.05 3.99 2.949 Australia 2.29 4.89 2.60

10 US 5.65 8.24 2.5911 Israel 1.51 3.93 2.4212 Spain 0.18 2.48 2.30

13 Switzerland 2.16 4.43 2.2714 Austria 0.81 2.98 2.1715 UK 4.35 6.49 2.1416 Ireland 0.87 2.43 1.5617 New Zealand 1.72 3.18 1.4618 Japan 2.24 3.62 1.3819 South Africa 1.21 1.83 0.6220 China 0.58 0.47 0.11

Table 3. Impact, citations and papers in clinical psychology and psy-chiatry of the top 20 countries for number of papers (19811998)

No. Country Impact Citations Papers

US 18.82 537,607 28,5632 UK 16.04 118,111 7,3633 Sweden 14.23 21,125 1,4854 Ireland 13.89 4,098 2955 Denmark 12.79 8,926 6986 Belgium 11.48 3,709 3237 Canada 11.32 48,399 4,2748 New Zealand 10.29 4,721 4599 Norway 10.21 5,900 578

10 Switzerland 10.07 6,537 64911 Finland 9.65 6,397 66312 Netherlands 9.56 8,143 85213 Australia 9.41 22,156 2,35514 Israel 8.76 5,542 63315 Germany 8.32 19,324 2,32216 Italy 8.15 7,017 86117 Austria 6.53 1,873 28718 Spain 6.38 2,509 39319 India 6.10 1,750 28720 France 3.20 5,724 1,789

Table 4. Top 20 countries for number of papers in clinical psycholo-gy and psychiatry in a cumulative 18-year period (19811998)ranked by change in impact for 19941998 compared to 19811985

No. Country Impact8185

Impact9498

Change in impact8185 vs. 9498

New Zealand 1.30 5.47 4.172 Germany 1.82 5.38 3.563 Austria 0.95 4.49 3.544 Ireland 2.42 5.73 3.315 Finland 1.92 4.90 2.986 Netherlands 2.12 4.49 2.377 US 4.01 6.04 2.038 UK 3.41 5.29 1.889 Switzerland 2.10 3.98 1.88

10 Norway 2.26 4.13 1.8711 Spain 0.71 2.47 1.7612 Israel 1.68 3.43 1.75

13 Canada 2.26 3.99 1.7314 Denmark 3.18 4.90 1.7215 Italy 1.92 3.31 1.3916 France 0.45 1.82 1.3717 Australia 2.08 3.20 1.1218 Belgium 4.10 4.69 0.5919 Sweden 3.62 3.90 0.2820 India 2.68 2.60 0.08

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Fig. 1. Citation impact of world regions ingeneral and internal medicine.

Fig 2. Citation impact in clinical psychologyand psychiatry.

The US and the UK are in the top position both for

number of papers and impact in clinical psychology andpsychiatry (table 3). Sweden, Ireland and Denmark followfor impact. New Zealand, Germany and Austria have dis-played the greatest change in impact (table 4). Figure 2outlines the citation impacts of the world regions: animpressive growth of Latin America can be observed.

These data deserve comment both as to the perfor-mance of individual countries and as to problems inassessing research.

Individual Countries

The main countries included in tables 14 are brieflydiscussed.

United States. The American prominence in medicalresearch appears to be obvious. This is not limited to thefact that the US shows the largest production of papers(around half of the world production) not only in generaland internal medicine and clinical psychology and psy-chiatry, but also in the other 13 fields not reported here. A

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selection bias of the ISI database may in part be responsi-ble for this prominence. The US has the highest impact in8 of the 15 fields (cardiovascular and respiratory medi-cine, gastroenterology, hematology, rheumatology, envi-ronmental and social medicine, surgery, radiology, nu-clear medicine and imaging, clinical psychology and psy-

chiatry) and ranks at least 3rd in the remaining fields.However, the American superiority is not as strong as itwas in the early eighties. There are fields (with pediatricsrepresenting the most striking example), where the growthof American research is inferior to several other coun-tries.

United Kingdom. This phenomenon is magnified byBritish medical research. The UK is 2nd for impact onlyin clinical psychology and psychiatry, gastroenterologyand surgery, whereas the picture was much brighter in theeighties.

Canada. The impact of Canadian papers is limited in

general and internal medicine and clinical psychology andpsychiatry. However, Canada has the highest impact inoncology, reproductive medicine and pediatrics, and isalways among the top 10 in the remaining fields. TheCanadian impact was also comparatively higher in theeighties.

Sweden. It has the highest impact in general and inter-nal medicine and anesthesia and intensive care, and it isalways among the top 10 in the remaining fields (3rd inclinical psychology and psychiatry). However, there is acomparative loss of ground in this latter field (table 4), asdiscussed in detail in previous papers [1, 3].

Denmark. It ranks 4th in general and internal medicine(where it shows impressive growth) and 5th in clinicalpsychology and psychiatry. It is 2nd in endocrinology,metabolism and nutrition and displays the greatestgrowth in pediatrics.

Netherlands. It ranks high in general and internal med-icine and in other fields and has the highest impact in clin-ical immunology and infectious disease.

Belgium. It ranks 6th both in general and internal med-icine and clinical psychology and psychiatry. However, itshows different progress in the two disciplines (tables 2,

4). It is 3rd in hematology and reproductive medicine.Italy. The case of Italy has been discussed in detail in

previous analyses [1, 3]. It shows spectacular growth ingeneral and internal medicine and anesthesia and inten-sive care and a negative trend in endocrinology, metabo-lism and nutrition. With France, Germany and Japan itshares the fact of having a large production of papers,which however generate a comparatively low number ofcitations. This phenomenon has been discussed in detail

for psychology and psychiatry [3] and neuroscience [4].Such a drop, of course, does not take place in every field.

France. The impact of French clinical research seemsto be very limited. It is among the top 10 countries only inendocrinology, metabolism and nutrition and radiology,nuclear medicine and imaging.

Germany. It ranks low as shown in tables 1 and 3,despite a good growth (tables 2, 4). It is among the top 10only in endocrinology, metabolism and nutrition (10th).

Japan. It is among the top 10 only in surgery (10th) anddoes not even reach the threshold for number of papers inclinical psychology and psychiatry.

Switzerland. It is among the top 10 in cardiovascularand respiratory system, gastroenterology and hepatology,endocrinology, metabolism and nutrition (where it ranksfirst), hematology, rheumatology, clinical immunologyand infectious disease, oncology, radiology, nuclear medi-cine and imaging, and pediatrics.

Ireland. It ranks very high and shows much growth inclinical psychology and psychiatry (tables 3, 4); it isamong the top 10 in reproductive medicine as well.

Australia. It is among the top 10 in general and internalmedicine, cardiovascular and respiratory system, gastro-enterology and hepatology, endocrinology, metabolismand nutrition, hematology (2nd), rheumatology, environ-mental and social medicine (2nd), anesthesia and inten-sive care, surgery, oncology, reproductive medicine, radi-ology, nuclear medicine and imaging.

New Zealand. It displays the highest growth in clinicalpsychology and psychiatry, and it is 10th in general andinternal medicine.

Assessing Research

Citation analysis, as an indirect measure of the scien-tific wealth of a nation, has a number of shortcomings.The first concerns the database, that has a clear preferencefor English language journals. Language discriminationmay account for the low citation rates of papers in lan-guages such as German and French, which are included in

the database [5]. A second shortcoming involves the factthat comparisons among countries are to some degreeconfounded, because a large and growing fraction ofscientific work involves international collaboration. Fi-nally, analysis of change in impact should be interpretedwith caution, since the countries that had the highestimpacts in 19811985 may display less growth than thosewhich had low impacts during those years. Nonetheless,citation analysis using the ISI database offers a number of

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helpful indicators for science and policy making [6, 7]. Inparticular, it may become a helpful tool for unravelinginteresting patterns in research which may be correlatedwith funding priorities. In several European countries,research progress may be hindered by a lack of competingopportunities and control of special interest groups [8],

which disregard scientific merit and clinical value. Use ofimpact factors of journals for evaluating individual re-search is a misleading tool [911], which lends itself tomanipulation. Moreover, citation analysis, in this con-text, appears to be a fairer and more objective assessmentof research than the impact factor as it may be based onseveral years, which, in many fields, is necessary for dis-closing citation patterns of papers which require a certain

time before exerting an influence on the scientific litera-ture. The citation analysis of individual countries in clini-cal medicine has yielded important observations. Sub-stantial differences in performance may reflect a numberof phenomena, such as the tradition of fields of excel-lence, different levels of priorities in investment and effi-

ciency of academic or research institutions. These issuesdeserve to be discussed and debated at all levels. We wel-come comments by our readers.

Acknowledgement

The authors are indebted to Nancy Bayers and David Pendlebury(ISI, Philadelphia) for their help and guidance.

References

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2 Fava GA, Montanari A: National trends ofresearch in psychology and psychiatry (19811995). Psychother Psychosom 1997;66:169174.

3 Fava GA, Montanari A: National trends ofresearch in behavioral sciences (19811996).Psychother Psychosom 1998;67:281301.

4 Fava GA, Montanari A: National trends ofresearch in neuroscience. Eur Neuropsycho-pharmacol 1998;8:349352.

5 Seglen PO: Citation and journal impact factors:Questionable indicators of research quality. Al-lergy 1997;52:10501056.

6 Garfield E, Welljams-Derof A: Citation data:Their use as quantitative indicators for scienceand technology evaluation and policy making.Sci Publ Policy 1992;19:321327.

7 May RM: The scientific wealth of nations.Science 1997;275:793796.

8 Fava GA: Conflict of interest and special inter-est groups: The making of a counter culture.Psychother Psychosom 2001;70:15.

9 Opthof T: Sense and nonsense about the im-pact factor. Cardiovasc Res 1997;33:17.

10 Hansson S: Impact factor as a misleading toolin evaluation of medical journals. Lancet 1995;346:906.

11 Fava GA, Ottolini F: Impact factors versusactual citations. Psychother Psychosom 2000;69:285286.