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Analysis of Scientific Production in Otolaryngology in Spain in the Period 2011–2015
Acta Otorrinolaringol Esp. 2018;69(5):275---282
www.elsevier.es/otorrino
ORIGINAL ARTICLE
Analysis of Scientific Production in Otolaryngology in Spain in the Period 2011---2015夽 Jose A. Lopez-Escamez,a,b,∗ Raquel Manrique-Huarte,c Eduardo Martin-Sanz,d Gabriel Trinidade , COMISIÓN DE INVESTIGACIÓN de la SEORL-CCC a
Otology & Neurotology Group CTS495, Department of Genomic Medicine-Centro de Genómica e Investigación Oncológica --Pfizer/Universidad de Granada/Junta de Andalucía GENYO, Granada, Spain b Department of Otolaryngology, Instituto de Investigación Biosanitaria ibs Granada, Hospital Universitario Virgen de las Nieves, Granada, Spain c Departamento de Otorrinolaringología, Clínica Universidad de Navarra, Pamplona, Spain d Servicio de Otorrinolaringología, Hospital Universitario de Getafe, Madrid, Spain e Servicio de Otorrinolaringología, Unidad de Otoneurología, Complejo Hospitalario Universitario de Badajoz, Badajoz, Spain Received 19 August 2017; accepted 12 September 2017
KEYWORDS Scientific publication; Otorhinolaryngology; Impact factor; Medical education
Abstract Introduction: Publishing in scientific journals is an indicator of hospital quality and has become a standard of excellence for medical doctors and institutions. The aim of the study is to identify the scientific publications performed by Otolaryngology Departments in Spain within the period 2011---2015 and to compare them to a previous period between 1998---2002. Material and methods: Original papers published by Otolaryngology Departments in Spain in PubMed within 2011---2015 were retrieved. They were classified according to the type of journal published (international or Acta ORL Espa˜ nola) and the following subspecialty areas: Otology, Audiology and Neuro-Otology, Head and Neck Surgery (including Oncology), Rhinology and Paediatric ENT. Hospitals were ranked according to: number of original papers, accumulated impact factor and total number of publications. Results: Between 2011 and 2015, 49 342 publications were included in PubMed, 1.44% from Otolaryngology Departments in Spain. Between 1998 and 2002, 3.80% publications were from Spanish ENT departments. Of the 712 papers published within the period 2011---2015, 389 were published in Acta ORL Espa˜ nola and 323 in international journals. From the latter, 20.7% belong to the Otology area, 19.2% to Audiology-Neuro-otology, 30.6% to Head and Neck Surgery, 15.2% to Rhinology and 3.4% to Paediatric ENT. Five tertiary centres published at least 10 original papers in the same period.
夽 Please cite this article as: Lopez-Escamez JA, Manrique-Huarte R, Martin-Sanz E, Trinidad G, COMISIÓN DE INVESTIGACIÓN de la SEORLna durante el periodo 2011-2015. Acta Otorrinolaringol Esp. CCC. Análisis de la producción científica en otorrinolaringología en Espa˜ 2018;69:275---282. ∗ Corresponding author. E-mail address: [email protected] (J.A. Lopez-Escamez).
2173-5735/© 2018 Sociedad Espa˜ nola de Otorrinolaringolog´ıa y Cirug´ıa de Cabeza y Cuello. Published by Elsevier Espa˜ na, S.L.U. All rights reserved.
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J.A. Lopez-Escamez et al. Conclusions: Spanish otolaryngology’s contribution to international journals has decreased in the last 12 years. A few institutions are responsible for the majority of publications and they have notably increased the cumulative impact factor. © 2018 Sociedad Espa˜ nola de Otorrinolaringolog´ıa y Cirug´ıa de Cabeza y Cuello. Published by Elsevier Espa˜ na, S.L.U. All rights reserved.
PALABRAS CLAVE Publicación científica; Otorrinolaringología; Factor de impacto; Educación médica
Análisis de la producción científica en otorrinolaringología en Espa˜ na durante el periodo 2011-2015 Resumen Introducción: La publicación de artículos científicos es un indicador de calidad del hospital y se ha convertido en un criterio de excelencia entre los indicadores clínicos que acreditan a un profesional o a una institución. Se evaluaron las publicaciones científicas realizadas en los servicios de otorrinolaringología espa˜ noles durante el período 2011-2015 comparándolas con el periodo 1998-2002. Material y métodos: Se extrajeron los artículos de Pubmed publicados por los servicios de ORL de Espa˜ na en el periodo 2011-2015, clasificándose según el tipo de revista (Acta OtorrinolaringolÓgica Espa˜nola o internacional) y el área de conocimiento: otología, audiología y otoneurología, cirugía de cabeza y cuello incluyendo oncología, rinología y ORL pediátrica. Se estableció un ranking de hospitales considerando el número total de originales, el factor de impacto acumulado y el número total de publicaciones. Resultados: En el periodo 2011-2015 se han identificado 49.342 publicaciones, de las cuales el 1,44% proceden de Espa˜ na, mientras que entre 1998-2002 el 3,80% proceden de Espa˜ na. De los 712 artículos hay 389 publicados en Acta OtorrinolaringolÓgica Espa˜nola y 323 internacionales. De estas últimas el 20,7% pertenecen a la sección de otología, el 19,2% a audiología-otoneurología, el 30,6% a cirugía de cabeza y cuello, el 15,2% a rinología y el 3,4% ORL pediátrica. Cinco centros hospitalarios publicaron al menos 10 artículos originales en el período estudiado. Conclusiones: La producción científica de la ORL espa˜ nola a nivel internacional ha descendido en los últimos 12 a˜ nos. Se observa un fenómeno de concentración en determinados centros, asociado a un incremento considerable del factor de impacto acumulado. © 2018 Sociedad Espa˜ nola de Otorrinolaringolog´ıa y Cirug´ıa de Cabeza y Cuello. Publicado por Elsevier Espa˜ na, S.L.U. Todos los derechos reservados.
Introduction Different models of medical education have been present throughout the history of medicine in the 19th and 20th centuries. From a predominant situation in the 19th century where clinical practice was founded on individual experience and conveyed through teachers, the publication of the Flexner report in 1910 led to a profound transformation in medical education.1 Taking the German model of medical education based on the book by Theodore Billroth ‘‘Über das Lehren und Lernen der medizinischen Wissenschaften an den Universitäten der deutschen Nation’’,2 Abraham Flexner proposed a reform of the medical education system based on biomedical research, which led to the creation decades later of the National Institute of Health. Twentieth century clinical medicine was mostly founded on research projects based on the scientific method, which were published in scientific journals following paired assessment of methodological quality. In 20th century medicine the publication of scientific articles became a clinical indicator of excellence which
validated a professional, a service or an institution.3 In fact, investigative activity and its bibliometric impact has become one of the essential requisites for university professor entitlement. Furthermore, in several hospital centres scientific production is a strategic indicator which conditions the recruitment criteria of medical personnel, not only due to the innovative vision of these institutions, but also from the added value that research and teaching activity offers these professionals. The raising of direct and indirect financial resources which research projects contribute to the institutions also plays a part.4 This growing interest in collecting and assessing the bibliography produced is responsible for many studies in different specialties.5---7 However, there are few studies which have assessed the research activity in the speciality of otorhinolaryngology (ENT) in Spain,8,9 and the analysis of bibliometric indicators which try to quantity the relevance of these publications.10 In 2003 a descriptive analysis of the scientific production of the ENT services was published by hospital centres and regions,8 but no subsequent studies have been performed to compare with it.
Analysis of Scientific Production in Otolaryngology in Spain in the Period 2011---2015 The purpose of this study is to evaluate scientific productions written for Spanish ENT services during the period 2011---2015 in the different specialised areas of knowledge and to compare the results with those of the abovementioned analysis carried out between 1998 and2002, using the same methodology.
Material and Methods Data Collection We identified the articles collected in PubMed (http://www.ncbi.nih.gov/PubMed) which had been published by ENT services in Spain using a search strategy designed for this purpose. The strategy consisted in a search limited to the management field (‘‘affiliation’’) combined with the following terms: Otorrinolaringologia OR Otorrino* OR Otorhinol* OR otolar* OR ENT [Affiliation] AND SPAIN, and combinations of all provinces in Spain, limited to searching from 2011 to 2015. The search of provinces was made in all official languages of Spain, considering the name of the capital, if it was different from the province, as occurs in Euskadi or in the island provinces. Furthermore, the Acta OtorrinolaringolÓgica Espa˜nolaindexes were reviewed, including all articles published between 2011 and 2015. The following information was obtained from each article: title, abstract, first author, principal author or senior author, journal, impact factor (IF), year, hospital to which the first author belongs, hospital to which the last author belongs, the province and autonomous community. All the articles whose main authors (first and last signatory) did not belong to an ENT service in Spain were considered collaborations with other services (i.e., ophthalmology, neurosurgery), other university departments or international collaborations. If the main authors were affiliated in other countries the articles were excluded for the effects of being attributable to Spanish ororhinolaryngology. In the case of multicentre articles, the works were only accounted for in a single centre and were attributed to the ENT service of the main authors (corresponding author).
Evaluation of Scientific Production The articles were classified according to the type of journal they were published in (Acta OtorrinolaringolÓgica Espa˜nola or other international journal). All the articles were classified in the 5 areas of knowledge depending on the abstract content: otology, audiology and otoneurology, head and neck surgery including oncology, rhinology, and paediatric ENT. Furthermore, the multicentre articles were identified with international collaboration to calculate the international reach of the research performed in Spain. The identified documents were added by provinces presenting their geographical distribution through publication maps which led to identifying the hospital which had the ENT services with the highest scientific production.
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Results During the period from 2011 to2015, the search in PubMed produced 49 342 publications of which 712 came from ENT services in Spain, which represents 1.44% of the total. The identified articles were 323 international and 389 published in the Acta OtorrinolaringolÓgica Espa˜nola. Of the international articles 24 were clinical cases and 299 were original articles or reviews, from 50 hospitals. Table 1 presents the total number of international publications per hospital, and the accumulated IF for the 20 first hospitals. The criteria for establishing a ranking of hospitals were: 1st total number of originals; 2nd accumulated IF; 3rd mean IF and 4th total number of publications. Only 5 hospital centres were able to publish at least 10 original articles during the 5 years of the study period: the Hospital Central of Asturias, the Clínica Universidad of Navarre, the Hospital Clinic of Barcelona, the Hospital la Paz of Madrid and the Hospital de Poniente de El Ejido, in Almeria. A research centre was attached to all of these services and each had an organised research group and contracted research personnel, which explains the research results obtained. These centres are: the Instituto Universitario de Oncología del Principado de Asturias (IUOPA) in Oviedo, the Centro de investigación Médica Aplicada (CIMA) in Pamplona, the Institut d’ investigacions Biomediques August Pi i Sunyer (IDIBAPS) in Barcelona, the Instituto de Investigación Hospital Universitario La Paz (IdiPAZ) in Madrid and the Centro de Genómica e Investigación Oncológica (GENyO) in Granada, recently opened in 2010. All the services of the beforementioned hospitals had an accumulated IF in 5 years >30. Table 2 contains the ranking of the first 20 hospitals according to its contribution to publications in the Acta OtorrinolaringolÓgica Espa˜nola, following the previously described criteria: 1st total number of originals; and 2nd total number of publications. The hospitals which contributed most articles to the journal Acta OtorrinolaringolÓgica Espa˜nola are the Hospital Central de Asturias, the Hospital Universitario de Valencia and the Complejo Hospitalario Insular Materno-infantil de Las Palmas. The additional Tables 1 and 2 (Appendix: additional material) include the complete list of the hospitals, ordered according to the before-mentioned criteria. In order to determine the geographical distribution of the hospitals with specialised research groups in each of the speciality areas we drew up 5 maps for the areas of otology, audiology otoneurology, head and neck surgery, rhinology and paediatric ENT. Of the 323 internationally identified publications, 67 (20.7%) correspond to otology. Fig. 1 presents the distribution by province of scientific production in otology, with confirmation that the greatest number of publications originate from Madrid (University Hospital La Paz and Hospital Puerta de Hierro-Majadahonda) and the Clínica Universidad de Navarra in Pamplona. Sixty two publications (19.2%) were classified into areas of audiology and otoneurology (Fig. 2), with observation that the centres leading scientific production in these areas are the Clínica Universidad de Navarra and the Centro de Genómica e Investigación Oncológica (Genyo) in Granada. The area of knowledge with the most scientific publications in Spain is head and neck surgery, and particularly
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Table 1 Hospitals With the Highest Number of Publications in Internationally Indexed Journals in PubMed During the 2011---2015 Period. The Multicentre Studies Were Assigned to the Centre of the Main Author. Position
Hospital
Total originals
AIF
Mean IF
Total publications
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20
Hospital Central de Asturias-IUOPA Clínica Universidad de Navarra Hospital Clinic Barcelona-IDIBAPS Hospital Universitario La Paz Hospital de Poniente-GENyO Hospital Lucus Augusti Lugo Hospital Universitario Salamanca Hospital Universitario Ramón y Cajal Hospital Universitario de Getafe Hospital Puerta de Hierro Majadahonda Hospital Santa Creu i Sant Pau, Barcelona Hospital Universitario de Valencia Hospital Universitario de Santiago Hospital Clínico Universitario de Granada Hospital Universitario de Henares Hospital Clínico San Carlos Madrid Hospital Son Espases, Palma de Mallorca Hospital Universitario Río Hortega Bellvitge Biomedical Research Institute Hospital Universitario Virgen del Rocío, Sevilla
49 36 22 21 14 9 7 7 7 7 6 4 4 3 3 3 3 3 2 2
169.15 51.60 105.59 39.45 34.33 20.19 16.98 13.95 12.42 10.64 18.27 10.90 7.42 5.00 4.28 3.73 3.00 2.14 12.56 8.04
3.19 1.43 4.22 1.72 2.45 2.52 2.43 1.74 1.77 0.97 3.05 2.18 1.86 1.67 1.43 1.24 1.00 0.71 6.28 4.02
53 36 25 23 14 8 7 8 7 11 6 5 4 3 3 3 3 3 2 2
AIF: accumulated impact factor.
Table 2 Period.
Hospitals With the Highest Number of Publications in ‘‘Acta Otorrinolaringológica Espa˜ nola’’ During the 2011---2015
Position
Hospital
Total originals
Total publications
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20
Hospital Central de Asturias-IUOPA Hospital Universitario Valencia Complejo Hospitalario Insular Materno Infantil Hospital Dr. Peset Valencia Hospital Santa Creu i Sant Pau, Barcelona Hospital Universitario Virgen del Rocío, Sevilla Hospital General de Catalu˜ na Hospital Universitario A Coru˜ na Hospital Universitario Marqués de Valdecilla Clínica Universidad de Navarra Hospital Clínico Universitario Lozano Blesa Hospital Universitario de Santiago Hospital Universitario La Paz Hospital Puerta de Hierro Majadahonda Hospital Universitario Miguel Servet Hospital Universitario Ramón y Cajal Hospital de Fuenlabrada Hospital de Poniente-GENyO Hospital Clinic Barcelona-IDIBAPS Hospital Universitario Río Hortega
19 13 9 7 6 5 5 4 4 3 3 3 3 3 3 3 3 3 2 2
30 26 11 9 11 13 5 6 5 6 5 5 5 4 4 4 3 3 5 5
oncology with 99 publications in the study period (30.6%, Fig. 3). The centre leading oncology of head and neck in Spain Hospital Central de Asturias, followed by the Hospital Clinic in Barcelona and several hospitals in Madrid. Forty nine publications (15.2%) were identified in the area of rhinology in the otorhinolaryngology services in Spain (Fig. 4). The ranking is led by the Hospital Clinic de
Barcelona, followed by the Hospital Central de Asturias and the Hospital General de Valencia. The area of our specialty with the smallest scientific production is paediatric ENT (Fig. 5). Just 11 international publications (3.4%) of scientific production show that only a few centres in Madrid and Barcelona carry out isolated research activity, but there is no group or service with a
Analysis of Scientific Production in Otolaryngology in Spain in the Period 2011---2015
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Projects 0 1-5 6-10 11-15 > 15
Figure 1
Distribution by province of the scientific production in otology (2011---2015).
Projects 0 1-5 6-10 11-15 > 15
Figure 2
Distribution by province of the scientific production in audiology and otoneurology (2011---2015).
stable line of research if we exclude the studies performed on cochlear implants.
Discussion The first conclusion of our study is that the scientific production of otorhinolaryngology increases considerably internationally. Thus, during the 1998---2002 period 18 472 articles were published worldwide, with 703 coming from Spain.8 Thirteen years later the number of publications increased by more than 250% worldwide, but scientific production in Spain remained static. The explanation for this stagnation was not limited to the single temporary factor of the financial crisis or the reduction of professionals dedicated to otorhinolaringology, but to a structural problem
related to the research training received by resident physicians in Spain. The residency training programme (MIR) in Spain does not contain a structured research programme in the speciality of otorhinolaringology, unlike other training models in Europe, United States and Canada. The number of hospitals with the capacity to obtain international publications remains stable (56 in 2002 compared with 50 in 2015), but a concentration of scientific production has been observed in certain centres. This phenomenon is associated with a considerable increase of accumulated IF in the centres at the top of the ranking. Thus, the Hospital Central de Asturias multiplied its IF by 9, the Clínica Universidad de Navarra did so by 4.5 and the Hospital La Paz of Madrid did so by 3. A special mention should go to the Hospital de Poniente which has multiplied its impact factor by 30, and the Hospital Clinic de Barcelona which multiplied its by
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Projects 0 1-5 6-10 11-15 > 15
Figure 3
Distribution by province of the scientific production in head and neck surgery, including oncologic surgery (2011---2015).
Projects 0 1-5 6-10 11-15 > 15
Figure 4
Distribution by province of the scientific production in rhinology (2011---2015).
20. This confirms the exponential growth of their research activity. There is a group of hospitals which had very modest research activity in 2002 (accumulated IF <1) and which are currently among the top 10 in the ranking. These emerging hospitals are the Hospital de Poniente, Hospital Lucus Augusti in Lugo, Hospital Universitario in Salamanca and Hospital Universitario in Getafe. Almost all the hospitals which lead in scientific production in otorhinolaringology have an associated biomedical research institute, with contracted research staff. This explains the difference observed in the publications. Furthermore the annual mean IF of hospitals at the top of the ranking is above 3, which indicates that the studies published in journals outside our speciality, enjoy greater dissemination than that of the ENT area. This is an important
factor for knowledge to be extended to the other biomedical sciences and for research in ENT to be evaluated in the same way as that of other clinical specialties. Notwithstanding, a high percentage of the studies are published in the journal Acta OtorrinolaringolÓgica Espa˜nola and differences may be observed regarding the volume of scientific production between the different autonomous communities. This fact is also present in other specialities such as internal medicine or primary healthcare.11 The Spanish journal should be the first destination of research studies made by resident physicians, so that they may familiarise themselves with the procedure of sending out and reviewing manuscripts. This is confirmed on observing that the leading hospitals in publications in Acta OtorrinolaringolÓgica have a large number of resident physicians in training.
Analysis of Scientific Production in Otolaryngology in Spain in the Period 2011---2015
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Projects 0 1-5 6-10 11-15 >15
Figure 5
Distribution by province of the scientific production in paediatric ENT (2011---2015).
Bibliometric indexes provide different tools with which to estimate the possible importance of an original article.12,13 Of these, the one which is usually employed is the IF, which is a value annually given to the journals where the original articles have been published. The IF thus analyses the relative importance of the journal, comparing it with all others published.14 The biggest stumbling block of the IF is that it does not directly assess the published work, but the journal as a whole. New bibliometric indicators, such as the number of citations each study has standardised by the number of worldwide mean citations for each speciality appears to be a much more objective indicator although at least a 5 years period is required for use to be unbiased. Furthermore there is a low level of IF or dissemination level of ENT journals in general within the global field of medicine, and therefore exclusive analysis of this index may lead to error. Publishing some studies in journals from a different speciality with a much higher IF may lead to some type of bias, due to the difficulty in comparing it with the journals of our speciality. The Science Citation Index also classifies journals according to specialities, which results in the ability to analyse the position of each journal and its distribution by quartile within each speciality. Given the low IF range in the international journals of our speciality (0.392---3.376 in 2016), measurement of those journals which are found in the first quartile may help researchers to choose which medium they wish to use to publish their work and the productivity between different areas of specialties may be compared relatively.15 During this study period, according to the Journal Citation Reports of the Web of Knowledge, the 3 journals with the highest IF index in our speciality were in Rhinology (FI=3.761), Hearing Research (FI=2.968) and Ear and Hearing (FI=2.842). A similar analysis of the Spanish scientific production in the ENT area from 15 years ago suggested a different panorama in the journals located in the first quartile. This fact confirms that the situation is changing, and
forces us to periodically review which are the most influential journals in our field. Interdisciplinary collaborations, inter-hospital (multicentre studies) and international studies demonstrate the capacity of interaction of otorhinolaringologists in forming research networks and participating in projects of greater scientific relevance. Although assessing the capacity for collaboration of the ENT services is beyond the objectives of this article, it is still easy to identify the groups with international collaborations, and those which produce regular multicentre publications. Again, these groups are organised around biosanitary research institutes or centres of thematic research centres of excellence. The healthcare research institutes are the result of the association of teaching hospitals and national health system researchers, university and other public and private research centres. This union promotes interaction between basic researchers and clinical researches and enables translational research that has the greatest impact on the health system and the country’s health. Since journals from other disciplines (genetics, immunology, cellular biology, internal medicine, oncology) are those with the highest IF. This type of multidisciplinary study notably increases the accumulated IF of the services. We are aware that the publication of scientific works is not the only way to achieve excellence in the different ENT services throughout Spain, but we are also aware that it is at least one of the most important ways to be able to compare the different areas of knowledge of our specialty both nationally and internationally. We have a responsibility in the training of the next generation of ENT specialists and we need to convey how to produce scientific material in this speciality. After the first step taken by many specialists in communicating their professional experiences in different national and international congresses, there is a need to progress by disseminating the research carried out through its publication in the different journals of our speciality.
282 The purpose of this analysis is to provide the closest possible view of Spanish scientific production in the ENT field. However, this approximation is not exempt from bias, as it is very difficult to find all the publications with the search criteria based exclusively on affiliation. Within each service there are functional units and the word otorhinolaryngology (or its derivatives) are not always included in the title of the article. Despite this limitation, the methodology employed means that these results may be compared with the situation from 12 years ago and may help to provide greater knowledge about the research activity of our speciality. Finally, there are numerous factors which may influence the quality of scientific production within the ENT services, including research training for specialists, investment in biomedical research in Spain, time available for specialists within the working day to develop research, appropriate familiarity with the English language, and even the importance scientific production usually carries in official medical exams aimed at gaining employment or a professional career. Research training acquired during the doctoral thesis is therefore a determining factor for maintaining continuous scientific production in otorhinolaryngology.10 It is therefore essential for medical specialists in training to acquire skills and improve research training when doing a doctoral thesis during residency or during the first few years of their chosen speciality. We believe the appropriate drive of each of these factors will foster worldwide progress in research of our speciality and will lead to increased international presence midterm for our specialists.
Conflict of Interests The authors have no conflict of interests to declare.
Acknowledgments Our thanks to all the otorhinolaringologists who have dedicated a part of their lives to making science.
Appendix. Supplementary Data Supplementary data associated with this article can be found, in the online version, at https://doi.org/10.1016/ j.otoeng.2017.09.002.
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References 1. Flexner A. Medical education in the United States and Canada. Washington, DC: Science and Health Publications, Inc.; 1910. 2. Billroth T. The medical sciences in the German Universities: with an introduction by William H. Welch. New York: The Macmillan Company; 1924. 3. Önder C, Erdil SE. Opportunities and opportunism: publication outlet selection under pressure to increase research productivity. Res Eval. 2017;26:66---77. 4. Chung SW, Clifton JS, Rowe AJ, Finley RJ, Warnock GL. Strategic faculty recruitment increases research productivity within an academic university division. Can J Surg. 2009;52:401---6. 5. Figueredo E, Mu˜ noz Blanco F. Evaluación y evolución de la producción científica de los departamentos de anestesiología espa˜ noles. Rev Esp Anestesiol Reanim. 2002;49:306---13. 6. López-Mu˜ noz F, Marin F, Boya J. Evaluación bibliométrica de la producción científica espa˜ nola en neurociencia. Análisis de las publicaciones de difusión internacional durante el periodo 1984---1993. Rev Neurol. 1996;24:417---26. 7. Bordons M, Zulueta MA, Barrigon S. Actividad científica de los noles más productivos en farmacología y farmacia grupos espa˜ durante el periodo 1986---1993 a través del Science Citation Index (SCI). Med Clin (Barc). 1998;111:489---95. 8. López-Escamez JA. Evaluation of scientific productivity at otorhinolaryngologic services in Spain in 1998---2002. Acta Otorrinolaringol Esp. 2003;54:646---52. 9. Encinas-Vicente A, Prim-Espada MP, Cenjor-Espa˜ nol C, de Diego-Sastre JI. Impact of otolaryngology theses in their authors’ scientific production. Acta Otorrinolaringol Esp. 2015;66:269---74. 10. Kumar MJ. Evaluating scientists: citations, impact factor, h-Index, online page hits and what else? IETE Tech Rev. 2009;26:165---9. 11. López-Torres Hidalgo J, Basora Gallisà J, Orozco Beltrán D, Bellón Saame˜ no JÁ. Bibliometric map of research done in primary care in Spain during the period 2008---2012. Aten Primaria. 2014;46:541---8. 12. Cami J. Impactolatría: diagnóstico y tratamiento. Med Clin (Barc). 1997;109:515---24. 13. López Pi˜ nero JM, Terrada ML. El consumo de información científica nacional y extranjera en las revistas médicas espa˜ nolas: un nuevo repertorio destinado a su estudio. Med Clin (Barc). 1994;102:104---12. 14. Weightman AL, Butler CC. Using bibliometrics to define the quality of primary care research. BMJ. 2011;342:d1083. 15. Trilla A, Amymerich M, Giol M, Carné X, Asenjo MA, Rodés J. Comparative analysis of articles published by Spanish authors (1993---1997) in biomedical journals with high impact factor. Med Clin (Barc). 2000;114:609---13.
www.elsevier.es/otorrino
ORIGINAL ARTICLE
Analysis of Scientific Production in Otolaryngology in Spain in the Period 2011---2015夽 Jose A. Lopez-Escamez,a,b,∗ Raquel Manrique-Huarte,c Eduardo Martin-Sanz,d Gabriel Trinidade , COMISIÓN DE INVESTIGACIÓN de la SEORL-CCC a
Otology & Neurotology Group CTS495, Department of Genomic Medicine-Centro de Genómica e Investigación Oncológica --Pfizer/Universidad de Granada/Junta de Andalucía GENYO, Granada, Spain b Department of Otolaryngology, Instituto de Investigación Biosanitaria ibs Granada, Hospital Universitario Virgen de las Nieves, Granada, Spain c Departamento de Otorrinolaringología, Clínica Universidad de Navarra, Pamplona, Spain d Servicio de Otorrinolaringología, Hospital Universitario de Getafe, Madrid, Spain e Servicio de Otorrinolaringología, Unidad de Otoneurología, Complejo Hospitalario Universitario de Badajoz, Badajoz, Spain Received 19 August 2017; accepted 12 September 2017
KEYWORDS Scientific publication; Otorhinolaryngology; Impact factor; Medical education
Abstract Introduction: Publishing in scientific journals is an indicator of hospital quality and has become a standard of excellence for medical doctors and institutions. The aim of the study is to identify the scientific publications performed by Otolaryngology Departments in Spain within the period 2011---2015 and to compare them to a previous period between 1998---2002. Material and methods: Original papers published by Otolaryngology Departments in Spain in PubMed within 2011---2015 were retrieved. They were classified according to the type of journal published (international or Acta ORL Espa˜ nola) and the following subspecialty areas: Otology, Audiology and Neuro-Otology, Head and Neck Surgery (including Oncology), Rhinology and Paediatric ENT. Hospitals were ranked according to: number of original papers, accumulated impact factor and total number of publications. Results: Between 2011 and 2015, 49 342 publications were included in PubMed, 1.44% from Otolaryngology Departments in Spain. Between 1998 and 2002, 3.80% publications were from Spanish ENT departments. Of the 712 papers published within the period 2011---2015, 389 were published in Acta ORL Espa˜ nola and 323 in international journals. From the latter, 20.7% belong to the Otology area, 19.2% to Audiology-Neuro-otology, 30.6% to Head and Neck Surgery, 15.2% to Rhinology and 3.4% to Paediatric ENT. Five tertiary centres published at least 10 original papers in the same period.
夽 Please cite this article as: Lopez-Escamez JA, Manrique-Huarte R, Martin-Sanz E, Trinidad G, COMISIÓN DE INVESTIGACIÓN de la SEORLna durante el periodo 2011-2015. Acta Otorrinolaringol Esp. CCC. Análisis de la producción científica en otorrinolaringología en Espa˜ 2018;69:275---282. ∗ Corresponding author. E-mail address: [email protected] (J.A. Lopez-Escamez).
2173-5735/© 2018 Sociedad Espa˜ nola de Otorrinolaringolog´ıa y Cirug´ıa de Cabeza y Cuello. Published by Elsevier Espa˜ na, S.L.U. All rights reserved.
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J.A. Lopez-Escamez et al. Conclusions: Spanish otolaryngology’s contribution to international journals has decreased in the last 12 years. A few institutions are responsible for the majority of publications and they have notably increased the cumulative impact factor. © 2018 Sociedad Espa˜ nola de Otorrinolaringolog´ıa y Cirug´ıa de Cabeza y Cuello. Published by Elsevier Espa˜ na, S.L.U. All rights reserved.
PALABRAS CLAVE Publicación científica; Otorrinolaringología; Factor de impacto; Educación médica
Análisis de la producción científica en otorrinolaringología en Espa˜ na durante el periodo 2011-2015 Resumen Introducción: La publicación de artículos científicos es un indicador de calidad del hospital y se ha convertido en un criterio de excelencia entre los indicadores clínicos que acreditan a un profesional o a una institución. Se evaluaron las publicaciones científicas realizadas en los servicios de otorrinolaringología espa˜ noles durante el período 2011-2015 comparándolas con el periodo 1998-2002. Material y métodos: Se extrajeron los artículos de Pubmed publicados por los servicios de ORL de Espa˜ na en el periodo 2011-2015, clasificándose según el tipo de revista (Acta OtorrinolaringolÓgica Espa˜nola o internacional) y el área de conocimiento: otología, audiología y otoneurología, cirugía de cabeza y cuello incluyendo oncología, rinología y ORL pediátrica. Se estableció un ranking de hospitales considerando el número total de originales, el factor de impacto acumulado y el número total de publicaciones. Resultados: En el periodo 2011-2015 se han identificado 49.342 publicaciones, de las cuales el 1,44% proceden de Espa˜ na, mientras que entre 1998-2002 el 3,80% proceden de Espa˜ na. De los 712 artículos hay 389 publicados en Acta OtorrinolaringolÓgica Espa˜nola y 323 internacionales. De estas últimas el 20,7% pertenecen a la sección de otología, el 19,2% a audiología-otoneurología, el 30,6% a cirugía de cabeza y cuello, el 15,2% a rinología y el 3,4% ORL pediátrica. Cinco centros hospitalarios publicaron al menos 10 artículos originales en el período estudiado. Conclusiones: La producción científica de la ORL espa˜ nola a nivel internacional ha descendido en los últimos 12 a˜ nos. Se observa un fenómeno de concentración en determinados centros, asociado a un incremento considerable del factor de impacto acumulado. © 2018 Sociedad Espa˜ nola de Otorrinolaringolog´ıa y Cirug´ıa de Cabeza y Cuello. Publicado por Elsevier Espa˜ na, S.L.U. Todos los derechos reservados.
Introduction Different models of medical education have been present throughout the history of medicine in the 19th and 20th centuries. From a predominant situation in the 19th century where clinical practice was founded on individual experience and conveyed through teachers, the publication of the Flexner report in 1910 led to a profound transformation in medical education.1 Taking the German model of medical education based on the book by Theodore Billroth ‘‘Über das Lehren und Lernen der medizinischen Wissenschaften an den Universitäten der deutschen Nation’’,2 Abraham Flexner proposed a reform of the medical education system based on biomedical research, which led to the creation decades later of the National Institute of Health. Twentieth century clinical medicine was mostly founded on research projects based on the scientific method, which were published in scientific journals following paired assessment of methodological quality. In 20th century medicine the publication of scientific articles became a clinical indicator of excellence which
validated a professional, a service or an institution.3 In fact, investigative activity and its bibliometric impact has become one of the essential requisites for university professor entitlement. Furthermore, in several hospital centres scientific production is a strategic indicator which conditions the recruitment criteria of medical personnel, not only due to the innovative vision of these institutions, but also from the added value that research and teaching activity offers these professionals. The raising of direct and indirect financial resources which research projects contribute to the institutions also plays a part.4 This growing interest in collecting and assessing the bibliography produced is responsible for many studies in different specialties.5---7 However, there are few studies which have assessed the research activity in the speciality of otorhinolaryngology (ENT) in Spain,8,9 and the analysis of bibliometric indicators which try to quantity the relevance of these publications.10 In 2003 a descriptive analysis of the scientific production of the ENT services was published by hospital centres and regions,8 but no subsequent studies have been performed to compare with it.
Analysis of Scientific Production in Otolaryngology in Spain in the Period 2011---2015 The purpose of this study is to evaluate scientific productions written for Spanish ENT services during the period 2011---2015 in the different specialised areas of knowledge and to compare the results with those of the abovementioned analysis carried out between 1998 and2002, using the same methodology.
Material and Methods Data Collection We identified the articles collected in PubMed (http://www.ncbi.nih.gov/PubMed) which had been published by ENT services in Spain using a search strategy designed for this purpose. The strategy consisted in a search limited to the management field (‘‘affiliation’’) combined with the following terms: Otorrinolaringologia OR Otorrino* OR Otorhinol* OR otolar* OR ENT [Affiliation] AND SPAIN, and combinations of all provinces in Spain, limited to searching from 2011 to 2015. The search of provinces was made in all official languages of Spain, considering the name of the capital, if it was different from the province, as occurs in Euskadi or in the island provinces. Furthermore, the Acta OtorrinolaringolÓgica Espa˜nolaindexes were reviewed, including all articles published between 2011 and 2015. The following information was obtained from each article: title, abstract, first author, principal author or senior author, journal, impact factor (IF), year, hospital to which the first author belongs, hospital to which the last author belongs, the province and autonomous community. All the articles whose main authors (first and last signatory) did not belong to an ENT service in Spain were considered collaborations with other services (i.e., ophthalmology, neurosurgery), other university departments or international collaborations. If the main authors were affiliated in other countries the articles were excluded for the effects of being attributable to Spanish ororhinolaryngology. In the case of multicentre articles, the works were only accounted for in a single centre and were attributed to the ENT service of the main authors (corresponding author).
Evaluation of Scientific Production The articles were classified according to the type of journal they were published in (Acta OtorrinolaringolÓgica Espa˜nola or other international journal). All the articles were classified in the 5 areas of knowledge depending on the abstract content: otology, audiology and otoneurology, head and neck surgery including oncology, rhinology, and paediatric ENT. Furthermore, the multicentre articles were identified with international collaboration to calculate the international reach of the research performed in Spain. The identified documents were added by provinces presenting their geographical distribution through publication maps which led to identifying the hospital which had the ENT services with the highest scientific production.
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Results During the period from 2011 to2015, the search in PubMed produced 49 342 publications of which 712 came from ENT services in Spain, which represents 1.44% of the total. The identified articles were 323 international and 389 published in the Acta OtorrinolaringolÓgica Espa˜nola. Of the international articles 24 were clinical cases and 299 were original articles or reviews, from 50 hospitals. Table 1 presents the total number of international publications per hospital, and the accumulated IF for the 20 first hospitals. The criteria for establishing a ranking of hospitals were: 1st total number of originals; 2nd accumulated IF; 3rd mean IF and 4th total number of publications. Only 5 hospital centres were able to publish at least 10 original articles during the 5 years of the study period: the Hospital Central of Asturias, the Clínica Universidad of Navarre, the Hospital Clinic of Barcelona, the Hospital la Paz of Madrid and the Hospital de Poniente de El Ejido, in Almeria. A research centre was attached to all of these services and each had an organised research group and contracted research personnel, which explains the research results obtained. These centres are: the Instituto Universitario de Oncología del Principado de Asturias (IUOPA) in Oviedo, the Centro de investigación Médica Aplicada (CIMA) in Pamplona, the Institut d’ investigacions Biomediques August Pi i Sunyer (IDIBAPS) in Barcelona, the Instituto de Investigación Hospital Universitario La Paz (IdiPAZ) in Madrid and the Centro de Genómica e Investigación Oncológica (GENyO) in Granada, recently opened in 2010. All the services of the beforementioned hospitals had an accumulated IF in 5 years >30. Table 2 contains the ranking of the first 20 hospitals according to its contribution to publications in the Acta OtorrinolaringolÓgica Espa˜nola, following the previously described criteria: 1st total number of originals; and 2nd total number of publications. The hospitals which contributed most articles to the journal Acta OtorrinolaringolÓgica Espa˜nola are the Hospital Central de Asturias, the Hospital Universitario de Valencia and the Complejo Hospitalario Insular Materno-infantil de Las Palmas. The additional Tables 1 and 2 (Appendix: additional material) include the complete list of the hospitals, ordered according to the before-mentioned criteria. In order to determine the geographical distribution of the hospitals with specialised research groups in each of the speciality areas we drew up 5 maps for the areas of otology, audiology otoneurology, head and neck surgery, rhinology and paediatric ENT. Of the 323 internationally identified publications, 67 (20.7%) correspond to otology. Fig. 1 presents the distribution by province of scientific production in otology, with confirmation that the greatest number of publications originate from Madrid (University Hospital La Paz and Hospital Puerta de Hierro-Majadahonda) and the Clínica Universidad de Navarra in Pamplona. Sixty two publications (19.2%) were classified into areas of audiology and otoneurology (Fig. 2), with observation that the centres leading scientific production in these areas are the Clínica Universidad de Navarra and the Centro de Genómica e Investigación Oncológica (Genyo) in Granada. The area of knowledge with the most scientific publications in Spain is head and neck surgery, and particularly
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Table 1 Hospitals With the Highest Number of Publications in Internationally Indexed Journals in PubMed During the 2011---2015 Period. The Multicentre Studies Were Assigned to the Centre of the Main Author. Position
Hospital
Total originals
AIF
Mean IF
Total publications
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20
Hospital Central de Asturias-IUOPA Clínica Universidad de Navarra Hospital Clinic Barcelona-IDIBAPS Hospital Universitario La Paz Hospital de Poniente-GENyO Hospital Lucus Augusti Lugo Hospital Universitario Salamanca Hospital Universitario Ramón y Cajal Hospital Universitario de Getafe Hospital Puerta de Hierro Majadahonda Hospital Santa Creu i Sant Pau, Barcelona Hospital Universitario de Valencia Hospital Universitario de Santiago Hospital Clínico Universitario de Granada Hospital Universitario de Henares Hospital Clínico San Carlos Madrid Hospital Son Espases, Palma de Mallorca Hospital Universitario Río Hortega Bellvitge Biomedical Research Institute Hospital Universitario Virgen del Rocío, Sevilla
49 36 22 21 14 9 7 7 7 7 6 4 4 3 3 3 3 3 2 2
169.15 51.60 105.59 39.45 34.33 20.19 16.98 13.95 12.42 10.64 18.27 10.90 7.42 5.00 4.28 3.73 3.00 2.14 12.56 8.04
3.19 1.43 4.22 1.72 2.45 2.52 2.43 1.74 1.77 0.97 3.05 2.18 1.86 1.67 1.43 1.24 1.00 0.71 6.28 4.02
53 36 25 23 14 8 7 8 7 11 6 5 4 3 3 3 3 3 2 2
AIF: accumulated impact factor.
Table 2 Period.
Hospitals With the Highest Number of Publications in ‘‘Acta Otorrinolaringológica Espa˜ nola’’ During the 2011---2015
Position
Hospital
Total originals
Total publications
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20
Hospital Central de Asturias-IUOPA Hospital Universitario Valencia Complejo Hospitalario Insular Materno Infantil Hospital Dr. Peset Valencia Hospital Santa Creu i Sant Pau, Barcelona Hospital Universitario Virgen del Rocío, Sevilla Hospital General de Catalu˜ na Hospital Universitario A Coru˜ na Hospital Universitario Marqués de Valdecilla Clínica Universidad de Navarra Hospital Clínico Universitario Lozano Blesa Hospital Universitario de Santiago Hospital Universitario La Paz Hospital Puerta de Hierro Majadahonda Hospital Universitario Miguel Servet Hospital Universitario Ramón y Cajal Hospital de Fuenlabrada Hospital de Poniente-GENyO Hospital Clinic Barcelona-IDIBAPS Hospital Universitario Río Hortega
19 13 9 7 6 5 5 4 4 3 3 3 3 3 3 3 3 3 2 2
30 26 11 9 11 13 5 6 5 6 5 5 5 4 4 4 3 3 5 5
oncology with 99 publications in the study period (30.6%, Fig. 3). The centre leading oncology of head and neck in Spain Hospital Central de Asturias, followed by the Hospital Clinic in Barcelona and several hospitals in Madrid. Forty nine publications (15.2%) were identified in the area of rhinology in the otorhinolaryngology services in Spain (Fig. 4). The ranking is led by the Hospital Clinic de
Barcelona, followed by the Hospital Central de Asturias and the Hospital General de Valencia. The area of our specialty with the smallest scientific production is paediatric ENT (Fig. 5). Just 11 international publications (3.4%) of scientific production show that only a few centres in Madrid and Barcelona carry out isolated research activity, but there is no group or service with a
Analysis of Scientific Production in Otolaryngology in Spain in the Period 2011---2015
279
Projects 0 1-5 6-10 11-15 > 15
Figure 1
Distribution by province of the scientific production in otology (2011---2015).
Projects 0 1-5 6-10 11-15 > 15
Figure 2
Distribution by province of the scientific production in audiology and otoneurology (2011---2015).
stable line of research if we exclude the studies performed on cochlear implants.
Discussion The first conclusion of our study is that the scientific production of otorhinolaryngology increases considerably internationally. Thus, during the 1998---2002 period 18 472 articles were published worldwide, with 703 coming from Spain.8 Thirteen years later the number of publications increased by more than 250% worldwide, but scientific production in Spain remained static. The explanation for this stagnation was not limited to the single temporary factor of the financial crisis or the reduction of professionals dedicated to otorhinolaringology, but to a structural problem
related to the research training received by resident physicians in Spain. The residency training programme (MIR) in Spain does not contain a structured research programme in the speciality of otorhinolaringology, unlike other training models in Europe, United States and Canada. The number of hospitals with the capacity to obtain international publications remains stable (56 in 2002 compared with 50 in 2015), but a concentration of scientific production has been observed in certain centres. This phenomenon is associated with a considerable increase of accumulated IF in the centres at the top of the ranking. Thus, the Hospital Central de Asturias multiplied its IF by 9, the Clínica Universidad de Navarra did so by 4.5 and the Hospital La Paz of Madrid did so by 3. A special mention should go to the Hospital de Poniente which has multiplied its impact factor by 30, and the Hospital Clinic de Barcelona which multiplied its by
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Projects 0 1-5 6-10 11-15 > 15
Figure 3
Distribution by province of the scientific production in head and neck surgery, including oncologic surgery (2011---2015).
Projects 0 1-5 6-10 11-15 > 15
Figure 4
Distribution by province of the scientific production in rhinology (2011---2015).
20. This confirms the exponential growth of their research activity. There is a group of hospitals which had very modest research activity in 2002 (accumulated IF <1) and which are currently among the top 10 in the ranking. These emerging hospitals are the Hospital de Poniente, Hospital Lucus Augusti in Lugo, Hospital Universitario in Salamanca and Hospital Universitario in Getafe. Almost all the hospitals which lead in scientific production in otorhinolaringology have an associated biomedical research institute, with contracted research staff. This explains the difference observed in the publications. Furthermore the annual mean IF of hospitals at the top of the ranking is above 3, which indicates that the studies published in journals outside our speciality, enjoy greater dissemination than that of the ENT area. This is an important
factor for knowledge to be extended to the other biomedical sciences and for research in ENT to be evaluated in the same way as that of other clinical specialties. Notwithstanding, a high percentage of the studies are published in the journal Acta OtorrinolaringolÓgica Espa˜nola and differences may be observed regarding the volume of scientific production between the different autonomous communities. This fact is also present in other specialities such as internal medicine or primary healthcare.11 The Spanish journal should be the first destination of research studies made by resident physicians, so that they may familiarise themselves with the procedure of sending out and reviewing manuscripts. This is confirmed on observing that the leading hospitals in publications in Acta OtorrinolaringolÓgica have a large number of resident physicians in training.
Analysis of Scientific Production in Otolaryngology in Spain in the Period 2011---2015
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Projects 0 1-5 6-10 11-15 >15
Figure 5
Distribution by province of the scientific production in paediatric ENT (2011---2015).
Bibliometric indexes provide different tools with which to estimate the possible importance of an original article.12,13 Of these, the one which is usually employed is the IF, which is a value annually given to the journals where the original articles have been published. The IF thus analyses the relative importance of the journal, comparing it with all others published.14 The biggest stumbling block of the IF is that it does not directly assess the published work, but the journal as a whole. New bibliometric indicators, such as the number of citations each study has standardised by the number of worldwide mean citations for each speciality appears to be a much more objective indicator although at least a 5 years period is required for use to be unbiased. Furthermore there is a low level of IF or dissemination level of ENT journals in general within the global field of medicine, and therefore exclusive analysis of this index may lead to error. Publishing some studies in journals from a different speciality with a much higher IF may lead to some type of bias, due to the difficulty in comparing it with the journals of our speciality. The Science Citation Index also classifies journals according to specialities, which results in the ability to analyse the position of each journal and its distribution by quartile within each speciality. Given the low IF range in the international journals of our speciality (0.392---3.376 in 2016), measurement of those journals which are found in the first quartile may help researchers to choose which medium they wish to use to publish their work and the productivity between different areas of specialties may be compared relatively.15 During this study period, according to the Journal Citation Reports of the Web of Knowledge, the 3 journals with the highest IF index in our speciality were in Rhinology (FI=3.761), Hearing Research (FI=2.968) and Ear and Hearing (FI=2.842). A similar analysis of the Spanish scientific production in the ENT area from 15 years ago suggested a different panorama in the journals located in the first quartile. This fact confirms that the situation is changing, and
forces us to periodically review which are the most influential journals in our field. Interdisciplinary collaborations, inter-hospital (multicentre studies) and international studies demonstrate the capacity of interaction of otorhinolaringologists in forming research networks and participating in projects of greater scientific relevance. Although assessing the capacity for collaboration of the ENT services is beyond the objectives of this article, it is still easy to identify the groups with international collaborations, and those which produce regular multicentre publications. Again, these groups are organised around biosanitary research institutes or centres of thematic research centres of excellence. The healthcare research institutes are the result of the association of teaching hospitals and national health system researchers, university and other public and private research centres. This union promotes interaction between basic researchers and clinical researches and enables translational research that has the greatest impact on the health system and the country’s health. Since journals from other disciplines (genetics, immunology, cellular biology, internal medicine, oncology) are those with the highest IF. This type of multidisciplinary study notably increases the accumulated IF of the services. We are aware that the publication of scientific works is not the only way to achieve excellence in the different ENT services throughout Spain, but we are also aware that it is at least one of the most important ways to be able to compare the different areas of knowledge of our specialty both nationally and internationally. We have a responsibility in the training of the next generation of ENT specialists and we need to convey how to produce scientific material in this speciality. After the first step taken by many specialists in communicating their professional experiences in different national and international congresses, there is a need to progress by disseminating the research carried out through its publication in the different journals of our speciality.
282 The purpose of this analysis is to provide the closest possible view of Spanish scientific production in the ENT field. However, this approximation is not exempt from bias, as it is very difficult to find all the publications with the search criteria based exclusively on affiliation. Within each service there are functional units and the word otorhinolaryngology (or its derivatives) are not always included in the title of the article. Despite this limitation, the methodology employed means that these results may be compared with the situation from 12 years ago and may help to provide greater knowledge about the research activity of our speciality. Finally, there are numerous factors which may influence the quality of scientific production within the ENT services, including research training for specialists, investment in biomedical research in Spain, time available for specialists within the working day to develop research, appropriate familiarity with the English language, and even the importance scientific production usually carries in official medical exams aimed at gaining employment or a professional career. Research training acquired during the doctoral thesis is therefore a determining factor for maintaining continuous scientific production in otorhinolaryngology.10 It is therefore essential for medical specialists in training to acquire skills and improve research training when doing a doctoral thesis during residency or during the first few years of their chosen speciality. We believe the appropriate drive of each of these factors will foster worldwide progress in research of our speciality and will lead to increased international presence midterm for our specialists.
Conflict of Interests The authors have no conflict of interests to declare.
Acknowledgments Our thanks to all the otorhinolaringologists who have dedicated a part of their lives to making science.
Appendix. Supplementary Data Supplementary data associated with this article can be found, in the online version, at https://doi.org/10.1016/ j.otoeng.2017.09.002.
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References 1. Flexner A. Medical education in the United States and Canada. Washington, DC: Science and Health Publications, Inc.; 1910. 2. Billroth T. The medical sciences in the German Universities: with an introduction by William H. Welch. New York: The Macmillan Company; 1924. 3. Önder C, Erdil SE. Opportunities and opportunism: publication outlet selection under pressure to increase research productivity. Res Eval. 2017;26:66---77. 4. Chung SW, Clifton JS, Rowe AJ, Finley RJ, Warnock GL. Strategic faculty recruitment increases research productivity within an academic university division. Can J Surg. 2009;52:401---6. 5. Figueredo E, Mu˜ noz Blanco F. Evaluación y evolución de la producción científica de los departamentos de anestesiología espa˜ noles. Rev Esp Anestesiol Reanim. 2002;49:306---13. 6. López-Mu˜ noz F, Marin F, Boya J. Evaluación bibliométrica de la producción científica espa˜ nola en neurociencia. Análisis de las publicaciones de difusión internacional durante el periodo 1984---1993. Rev Neurol. 1996;24:417---26. 7. Bordons M, Zulueta MA, Barrigon S. Actividad científica de los noles más productivos en farmacología y farmacia grupos espa˜ durante el periodo 1986---1993 a través del Science Citation Index (SCI). Med Clin (Barc). 1998;111:489---95. 8. López-Escamez JA. Evaluation of scientific productivity at otorhinolaryngologic services in Spain in 1998---2002. Acta Otorrinolaringol Esp. 2003;54:646---52. 9. Encinas-Vicente A, Prim-Espada MP, Cenjor-Espa˜ nol C, de Diego-Sastre JI. Impact of otolaryngology theses in their authors’ scientific production. Acta Otorrinolaringol Esp. 2015;66:269---74. 10. Kumar MJ. Evaluating scientists: citations, impact factor, h-Index, online page hits and what else? IETE Tech Rev. 2009;26:165---9. 11. López-Torres Hidalgo J, Basora Gallisà J, Orozco Beltrán D, Bellón Saame˜ no JÁ. Bibliometric map of research done in primary care in Spain during the period 2008---2012. Aten Primaria. 2014;46:541---8. 12. Cami J. Impactolatría: diagnóstico y tratamiento. Med Clin (Barc). 1997;109:515---24. 13. López Pi˜ nero JM, Terrada ML. El consumo de información científica nacional y extranjera en las revistas médicas espa˜ nolas: un nuevo repertorio destinado a su estudio. Med Clin (Barc). 1994;102:104---12. 14. Weightman AL, Butler CC. Using bibliometrics to define the quality of primary care research. BMJ. 2011;342:d1083. 15. Trilla A, Amymerich M, Giol M, Carné X, Asenjo MA, Rodés J. Comparative analysis of articles published by Spanish authors (1993---1997) in biomedical journals with high impact factor. Med Clin (Barc). 2000;114:609---13.