Letters to the Editor
To the Editor:
In a recent article in Academic Medicine, Gozu et al1 concluded that international medical graduates (IMGs) are more likely to be less fatigued and have higher self-esteem and personal growth than U.S. medical graduates. They state that the self-assessment scales utilized in the study “have established validity evidence”: the Iowa Fatigue Scale, Perceived Stress Scale (PSS), Rosenberg Self-Esteem Scale (RSES), and Personal Growth Scale. However, we maintain that the cross-cultural validity of these scales for the extremely heterogeneous IMG group is questionable. Hence the data require cautious interpretation.
First, use of the Likert scale can generate variability of responses in different cultural groups.2 Chosen numbers on the scale may not accurately reflect the degree of the individual's psychometric constructs. Individuals in some cultures may exhibit a negative-item bias, and individuals in others tend to avoid extreme options.3 Additionally, the threshold for reporting any psychological status publicly may also vary by the learned experiences of persons within individual cultures.
Second, the context of an IMG's acculturation is essential in examining his or her psychological conditions. The questions in the PSS4 are so broad that they can mask some stresses provoked by unique challenges IMGs face during residency. Without stimulating a recall of each specific situation, subconscious and emotionally charged stresses may not surface.
Third, the type and heterogeneity of the populations previously examined for the scales should be equivalent to the population the authors investigated. The existing studies with the RSES sampled relatively homogeneous high school and college students,3,5 not culturally diverse medical graduates.
Culture influences cognitive processes that determine scores on the scales and can lead to variability of responses. When assessing IMGs, the multilayered cultures and contexts that they have lived through should not be ignored.
Keiichiro Narumoto, MD
Faculty development fellow, Department of Family Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania; firstname.lastname@example.org.
Stephen A. Wilson, MD, MPH
Faculty development fellowship program director and faculty member, Department of Family Medicine, University of Pittsburgh, UPMC St. Margaret Family Medicine Residency, Pittsburgh, Pennsylvania.
1 Gozu A, Kern DE, Wright SM. Similarities and differences between international medical graduates and U.S. medical graduates at six Maryland community-based internal medicine residency training programs. Acad Med. 2009;84:385–390.
2 Lee JW, Jones PS, Mineyama Y, Zhang ZE. Cultural differences in responses to a Likert scale. Res Nurs Health. 2002;25:295–306.
3 Schmitt DP, Allik J. Simultaneous administration of the Rosenberg Self-Esteem Scale in 53 nations: Exploring the universal and culture-specific features of global self-esteem. J Pers Soc Psychol. 2005;89:623–642.
4 Cohen S, Kamarck T, Mermelstein R. A global measure of perceived stress. J Health Soc Behav. 1983;24:385–396.
5 Rosenberg M. Society and the Adolescent Self-Image. Rev ed. Middletown, Conn: Wesleyan University Press; 1989.