Academic dermatology in Australia and New Zealand between 2017 and 2022: A cross‐sectional bibliometric analysis

Academic dermatologists in Australia and New Zealand provide high‐quality and meaningful contributions to the understanding of disease and therapeutic translational research. Concerns have been raised by the Australian Medical Association regarding the decline of clinical academics in Australia as a whole, however, such trends in scholarly output have not previously been analysed for Australasian dermatologists.


INTRODUCTION
Academic medicine rests on the work of clinician scientists who are able to conduct and critically evaluate scientific research and integrate it into the clinical context. Ultimately, this process allows for streamlined translational research centred on improving understanding of disease and patient care. In the last century, approximately half of Nobel Laureates in physiology and medicine were clinician scientists, highlighting the invaluable contributions of this community to the field of science. 1 Unfortunately, the proportion of active clinical academics has been declining in Australia and New Zealand in recent decades, with expected downstream repercussions on research output, medical education and ultimately health outcomes. 2 Decreasing support for clinician scientists in terms of funding, infrastructure and mentorship programs has been highlighted as a key reason for their decline. 3 This has resulted in plans by the Australian Medical Association (AMA) focusing on incorporating basic science research into medical school curricula, increasing funding for academic positions and establishing mentorship programs for early career clinician researchers. 4 Translational research is particularly important in dynamic fields such as dermatology, in which an improved understanding of disease pathology has resulted in the development of treatments with unprecedented efficacy in the last decade. For example, immunological research into psoriasis vulgaris has resulted in a recent paradigm shift from its characterization as a T H 1-to T H 17-mediated dermatosis, 5 leading to highly effective treatments targeting this axis. 6 Growing appreciation of the clinical effects of molecular aberrancies in cutaneous melanoma such as BRAF or NRAS gene mutations 7 have also resulted in the development of personalized diagnostic and screening guidelines for such patients. 8,9 High levels of education and research exposure are therefore integral for dermatologists to provide up-to-date evidence-based care as well as to further advance the field.
A recent Editorial by Khosrotehrani et al. discussed barriers to the training and retention of academic dermatologists in Australia. 10 Research experience as a core selection criterion for College applicants was highlighted as a strategy to encourage enthusiasm for dermatology research among junior trainees. Proposed challenges included a lack of established infrastructure for laboratorybased research, time and financial constraints for trainees undergoing clinical rotations and examinations, and limited on-site presence in teaching hospitals resulting in decreased inter-speciality research opportunities.
A number of bibliographic measures are used to assess academic output. These include scholarly output (number of peer-reviewed publications, 'Np'), citation counts, H index and field-weighted citation impact (FWCI). The H Index is an author-level metric to quantify the cumulative impact of an author's scholarly output and performance, as described by Hirsch 11 This provides a reference for the broader influence of an individual's work, with the highest number H indicating a researcher has at least H number of papers cited at least H times each. The FWCI is a ratio of the number of received citations to the number of expected citations in the field. For example, an FWCI of 1 indicates other bibliographic variables were comparable to male dermatologists. However, women were underrepresented in positions of academic leadership-comprising only 32% of this cohort despite representing 55% of dermatologists. Professors were also significantly more likely to have higher bibliographic outcomes than associate professors. Finally, analysis of recent College graduates highlighted a significant decline in bibliometric outcomes pre-and post-fellowship.

Conclusion:
Overall, our analysis identifies a trend towards decreased research output by dermatologists in Australia and New Zealand in the last 5 years.
Strategies to support dermatologists in research endeavours, particularly women and recent graduates, will be essential in maintaining strong scholarly output among Australasian dermatologists and thereby sustaining optimal evidencebased patient care. the average number of citations according to the global average in the field, whereas an FCWI of 1.78 indicates 78% more citations than the global average.
We aimed to assess the academic output of dermatologists in Australia and New Zealand in the preceding 5 years (2017-2022). This includes the overall trajectory of academic output and other bibliographic variables during this time period. In addition, to highlight differences in academic output based on demographic variables, subgroup analyses will include output relative to gender in this cohort of dermatologists and the association between academic appointments and bibliographic outcomes. Finally, to explore the effects of College research requirements on fostering the development of clinician scientists, we compare the scholarly output of dermatologists in the 5 years preceding and 5 years following the fellowship.

METHODS
This bibliographic analysis was granted ethics approval by the South Western Sydney Area Health Service Human Research Ethics Committee. Data collection and analyses were conducted in January and February 2023.
We obtained a list of all registered dermatologists in Australia and New Zealand from publicly available information provided by the website of the Australasian College of Dermatologists (https://www.dermc oll.edu.au/). Each name was then manually matched with a research profile on Scopus (https://www.scopus.com/), ensuring the location of the researcher and dermatologist was consistent.
Information collated included demographic data (gender) as well as overall (lifetime) bibliographic data (H index) and bibliographic variables pertinent to the years of interest (2017-2022). These variables included scholarly output (number of publications), the total number of citations (of works published between 2017 and 2022) and the FWCI between 2017 and 2022. Each bibliographic variable was analysed for all dermatologists, along with a sub-analysis of those holding academic positions (associate professor or professor). Additionally, all bibliographic variables were analysed after stratification by gender.
The relationship between scholarly output and awarding of a dermatology fellowship was examined in a subpopulation of dermatologists. Dermatologists with a verified fellowship award date between 2009 and 2017 who had Scopus data for the 5 years prior to being awarded fellowship and 5 years post-awarding of fellowship were identified. The same bibliographic variables (scholarly output, citation count, FWCI and H Index) were examined in this subgroup of recently graduated dermatologists.
Statistical analysis utilised non-parametric tests given the non-Gaussian nature of the data. Wilcoxon rank-sum tests were used to compare two discrete groups and oneway ANOVA for multiple groups was compared. P < 0.05 was considered significant and adjustment for multiple comparisons using the Benajmini-Hochberg procedure.
Graphpad Prism 9.4.1 was used to analyse all data.

RESULTS
A total of 463 practising dermatologists were identified in Australia and New Zealand in January 2023. Of those 463 dermatologists, 372 (80.3%) were successfully matched with scholarly output (publications) on Scopus ( Figure S1). Of these 372 dermatologists, 167 were male (45.0%) and 205 female (55.0%), while 31 individuals (8.4%) held formal academic positions as associate professors (n = 19) or professors (n = 12). Of these individuals, 21/31 (67.7%) were male and 10/21 (32.3%) were female. One hundred and twenty-two (32.8%) dermatologists had no scholarly output recorded in the last 5 years. Sixtynine individuals (18.5%) had only one publication and 181 (48.7%) had more than one publication between the years 2017-2022. Further information regarding citation counts, FWCI and H index is presented in Table 1. The distribution of scholarly output, citations, FWCI and H index is presented in Figure 1. The vast majority of dermatologists demonstrated data points that clustered near the bases of the graphs. The median scholarly output was 3 (IQR = 1-8), and the median citations were 14 (IQR = 3-72). The median FWCI was 0.64 (IQR = 0.29-1.37), and the median H index was 4 (IQR = 2-7).
Regarding the changes in scholarly output over time, the median number of publications over the years 2017-2022 decreased and approached but did not reach statistical significance (one-way ANOVA p = 0.08) ( Figure 2). Over the same time period, however, there were significant decreases in a median number of citations as well as the FWCI (one-way ANOVA p < 0.01 and p = 0.02, respectively). These findings suggest a disproportionate reduction in the publication of high-impact works relative to the total number of publications from Australian dermatologists between 2017 and 2022.
Notably, the proportion of female dermatologists holding an associate or full professor positions at 32% was significantly lower than the proportion of female dermatologists overall at 55% (chi-square p = 0.01). Stratification by gender revealed significant differences between groups for scholarly output. The mean number of publications for females was 13 (SD = 19.7; Range 0-193) and for males was 7 (SD = 26.9; range 0-183) (Wilcoxon rank-sum test p = 0.01). Between male and female dermatologists, there were otherwise no significant differences in citation counts (mean 152 versus 79, respectively; p = 0.24), H index (mean 7.8 versus 6.0, respectively; p = 0.17) or FWCI (mean 0.98 versus 1.09, respectively; p = 0.91). These differences in bibliographic outcomes by gender subgroups are summarized in Figure S2.
Regarding dermatologists in academic leadership positions between, the median H index for associate professors was 16 (IQR = 9-21) and for professors was 31 (IQR 22-40), which was statistically significant T A B L E 1 Characteristics of the 372 dermatologists in Australia and New Zealand included in the analysis, including bibliographic variables (overall and stratified by gender and positions of academic leadership). (Wilcoxon rank-sum test p < 0.01). The median citation count (for works published between 2017 and 2022) of 146 (IQR = 73-347) for associate professors was likewise significantly lower than for professors at 551 (IQR = 159-2424) (Wilcoxon rank-sum test p = 0.02). Similarly, scholarly output in his time period was lower with a median of 15 for associate professors (IQR = 8-25) compared to 71 for professors (IQR = 29-125) (Wilcoxon rank-sum test p < 0.01). These differences in bibliographic output between associate professors and professors are summarized in Figure 3. There was no significant difference between the bibliographic variables between men and women in academic dermatology positions, as shown in Figure S3.

Variable
When assessing the trend of bibliographic outcome variables for the 5 years pre-and post-fellowship (n = 30), a significant decrease in academic engagement postfellowship was observed. Scholarly output declined significantly (p = 0.04 as measured by one-way ANOVA) post-fellowship compared to pre-fellowship in this subpopulation. The median citation count also declined significantly over the period examined (p = 0.003 by one-way ANOVA). These changes pre-and post-fellowship are summarized in Figure 4. Median FWCI also declined over the period examined (p = 0.02 by one-way ANOVA) (data not shown). No significant differences were seen in the scholarly output or number of citations when stratified by gender (data not shown).

DISCUSSION
Overall, bibliographic data demonstrates that the majority of practising Australian and New Zealand dermatologists actively contribute to academic dermatology through scholarly output, with 67% publishing at least one paper in the last 5 years. Additionally, the quality of scholarly output is reflected in the active citations these publications are receiving. However, our results demonstrate a significant decline in the number and citations of academic output over the last 5 years. This is likely multifactorial and may have been impacted by the COVID-19 pandemic and more dermatologists reaching retirement age. Another concerning potential contributor is the decrease in the numbers of academic dermatologists, as observed in medicine as a whole. 2,4 Despite comprising a smaller cohort than in other countries, Australian academic dermatologists have historically produced disproportionately high-impact publications. In an international bibliometric analysis of dermatological research from 1985 to 2014 by Chen and Wu, Australia was ranked 11th globally (H index 105) with a greater increase in scholarly output over time than in some larger, higher-ranking countries. 12 For example, papers published by Australian dermatologists increased from 400 in 1985-1994 to 4452 in 2005-2014 (a 1013% increase over 30 years), compared to an increase from 20,598 to 48,472 papers by US dermatologists (ranked first by H index at 237) between the same two time periods (a 135% increase). The number of citations of papers from Australian dermatologists also grew markedly by 392% (9213-45,354) in the same 30-year period, compared to a 27% increase for US dermatologists (330,947-420,315). As such, any decline in dermatologic research in Australia and New Zealand raises concerns regarding a reduction of such high-quality academic output momentum.
The effects of a country's population size on academic output were also assessed in a bibliometric analysis by Gantenbein et al. who reviewed overall scholarly output (on Scopus, PubMed, Embase and Web of Science) up to 2019. 13 This analysis observed a global upwards trend in dermatological publications, particularly in topics such as melanoma, psoriasis and acne. Notably, while Australia was ranked 11th overall in scholarly output, the adjusted publication rate per million population was higher than countries such as the US, Germany and the UK (ranked first, second and third in academic output, respectively). However, few studies evaluate trends in other scholarly output measures such as the H index, FWCI or citation count over time, as in our analysis. Stratification by gender illustrated a greater level of scholarly output associated with females compared with males, and no significant differences in citations, FWCI or H index. Conversely, a similar bibliographic study of Canadian dermatologists observed a higher H index for male than female dermatologists, 11.2 versus 5.6, respectively. 14 However, using the H index as the sole measure of scholarly output is problematic, as acknowledged by the study authors, as it is dependent on the length of an individual's academic career. Comparing the equivalent research outputs of Australasian male and female dermatologists to the male predominance in academic leadership positions is striking. This confirms an established phenomenon in academic medicine as a whole and highlights the need for targeted measures to overcome such inequity. 15 One potential explanation is that appointment to academic leadership positions lags behind current trends in bibliographic variables. Hopefully, in coming years, we will see greater gender equality in academic dermatology leadership positions to reflect the current gender proportions of dermatologists in Australia and New Zealand. Statistically significant differences in bibliographic variables were seen between associate professors and professors in dermatology, with greater variability seen in the higher appointments. These outcomes validate the use of bibliographic measures with regards to academic positions in dermatology in Australasia. Again, this may be reflective of historical high output researchers as evidenced by the significantly higher H index for full versus associate professors (median 31 versus 16). This difference has been observed in other bibliometric studies, such as one analysis of US dermatologists calculating a similarly higher median H index of 21 (IQR 7-42) for full professors compared to 8 (IQR 3-17) for associate professors. 16 Similarly, a study of Canadian dermatologists calculated that full professors had a higher mean H index than associate professors and clinical lecturers (37 versus 12 and 3, respectively). 14 While these findings may be due in part to the higher scholarly requirements for academic progression to full professors, our analysis also demonstrated that active scholarly output from 2017 to 2022 remained higher for full professors than for associate professors.
Among the more insightful findings of our analysis was that academic output in recent graduates peaks prior to fellowship, suggesting that research may be considered 'means to an end' to access dermatology training. This is likely compounded by insufficient post-fellowship academic pathways available to encourage new fellows to pursue academic dermatology, as with other specialities. 2 Whether this suggests a need to consider alternate strategies to promote and retain clinician scientists in dermatology in Australia and New Zealand, such as combined MD-MPhil or MD-PhD fellowship programs as in other countries, 10 requires further evaluation. Of note, the Canadian bibliometric analysis demonstrated that dermatologists who held PhD degrees were significantly more likely to have an above-average H index (odds ratio 3.39). 14 However, there is also a need to consider the impact of Australian dermatologists relocating to rural and remote areas post-fellowship given the significant shortage of specialists in these areas. 17 Such dermatologists may be under more time constraints due to relatively higher patient loads as well as reduced access to large clinical datasets with which to conduct academic research. A bibliometric analysis of Spanish dermatologists observed that, expectedly, more high-impact papers (measured by citation count) were produced in larger academic centres in major cities. 18 Isolated Australian dermatologists may therefore benefit from remote inclusion in conducting clinical trials, increasingly normalised after the COVID-19 pandemic, 19 to encourage ongoing engagement with clinical and translational research.
The limitations of this analysis include restrictions to the years available to analyse through Scopus, although our primary aim was to evaluate bibliographic output in the last 5 years. Our analysis was also limited to fellows of the Australian and New Zealand colleges of dermatology and therefore does not include the research output of current trainees who are likely to influence bibliometric data in the coming years post-fellowship. Moreover, there is a potential bias against recently published articles or younger dermatologists not having time to accumulate citations -however, this was mitigated by the use of other dynamic measures such as scholarly output pertaining to the years of interest (2017-2022).

CONCLUSION
In conclusion, our bibliometric study critically evaluates the scholarly output of dermatologists in Australia and New Zealand over the last 5 years. While most of the included dermatologists had evidence of active engagement with academic research, in the form of peer-reviewed scholarly output, we identified an overall trend towards fewer publications, citations and a decrease in FWCI for articles published in 2017-2022. These highlight the need to consider strategies by Australasian Colleges to support and encourage academic research among dermatologists, as with the AMA plan.
Moreover, subgroup analyses highlighted that female dermatologists published more papers between 2017 and 2022, and had comparable H index, FWCI and citations to their male counterparts, including when stratified by academic leadership positions. This is in striking contrast to the underrepresentation of women in these leadership positions (associate or full professors) in dermatology and underlies a need for targeted measures to counteract this inequity, such as dedicated funding and mentorship programs for female academic dermatologists. Finally, there was a significant trend towards less scholarly output by recent College graduates, emphasising the need for strategies to promote ongoing academic engagement post-fellowship beyond the research requirements for program selection itself.

FUNDING INFORMATION
J.P.P. is supported by an Australian government research training program (RTP) scholarship.