[lachenmayer]

This sounds extremely low to me, but looking at the list of top journals sorted by Impact Factor on https://journal.komci.org/SearchJournal.php (you have to choose "Impact factor" in the "Sort results by" dropdown, as it does not generate a useful URL), the top journal only has an IF of 0.791.

I don't really know anything about the medical publishing world, but I would have expected a top journal to be cited much more?

[repsilat]

If most papers have dozens of citations, shouldn't each paper on average be cited dozens of times? Obviously with massive skew.