Intra-And Intercultural Comparisons of the Personality Profiles of Medical Students in Argentina and the United States
Rimoldi, Horacio J. A., Raimondo, Roberto, Erdmann, James B., Hojat, Mohammadreza, Adolescence
Cross-cultural studies on psychosocial factors that can influence medical students' and physicians' performance are scarce, despite the consensus among medical educators that psychosocial attributes are among the multiple facets of physicians' clinical competence (Gonnella, Hojat, Erdmann, & Veloski, 1993a). In addition to personality attributes, cultural factors contribute to both patients' and physicians' behavior (Guillemin, Bombardier, & Beaton, 1993) and may influence academic performance. An important issue that needs empirical scrutiny is whether personal and psychosocial attributes that predict academic achievement in medical school and professional performance in medical practice vary in different cultures.
Evidence suggests that the most significant predictor of future academic success in health care education, like other professional schools, is past academic performance (Blacklow, Goepp, & Hojat, 1991; Campbell & Dickson, 1996; Glaser, Hojat, Veloski, Blacklow, & Goepp, 1992; Gonnella & Hojat, 1983; Hojat, Gonnella, Veloski, & Erdmann, 1993; Hojat, Gonnella, Erdmann, & Veloski, 1997; Lyons, Grifone-Field, Hyslop, & Hoertz, 1993; Rosenfeld, Hojat, Veloski, Blacklow, & Geopp, 1992). Although this view has been supported in different cultures, it appears to be more applicable when measures of knowledge attainment are investigated.
Other evidence suggests that when clinical performance rather than knowledge attainment is taken into consideration, previous academic performance loses some of its predictive strength, and psychosocial attributes take on increased importance in predicting success (Gonnella, Hojat, Erdmann, & Veloski, 1993a, 1993b, 1993c; Hojat, Robeson, Damjanov, Veloski, & Glaser, 1993; Hojat, Vogel, Zeleznik, & Borenstein, 1988). These findings are consistent with the performance paradigm in medicine suggested by Gonnella, Hojat, Erdmann, and Veloski (1993c). These researchers propose that in addition to acquired factual knowledge and skills, personality factors contribute to academic and professional success (Hojat, Glaser, & Veloski, 1996; Hojat, Robeson et al., 1993; Hojat et al., 1988). This proposition is further supported by recently published works that suggest it is not solely academic achievement (e.g., grades) or cognitive abilities (e.g., intelligence quotient, or I.Q.), but also psychosocial attributes (e.g., p ersonality, and emotional quotient, or E.Q.), that can enhance professional effectiveness (Goleman, 1995; Mayer & Salovey, 1995).
Further support for the importance of psychosocial factors in academic performance in medical school and beyond is provided by the findings that suggest the power of prediction is enhanced when psychosocial attributes are included in the prediction models (Hojat, Robeson, Damjanov, Veloski, & Zeleznik, 1992; Hojat, Vogel, & Zeleznik, 1988; Zeleznik et al., 1988; Keck et al., 1979). This phenomenon of increased shared variance was also noticed when personality scales were added to the admission measures in predicting performance in the first and second years of medical school and scores on medical licensing examinations (see for example Hojat, Vogel et al., 1988; Hojat, Gonnella et al., 1992; Hojat, Robeson et al., 1993).
Kegel-Flom (1975) found that peer ratings of residents could also be predicted by a combination of personality inventory measures. Hunt and colleagues (1987) compared the performance of residents who had academic difficulties in medical school (considered for dismissal or probation) with that of their counterparts without such difficulties. The residents who had academic difficulties generally received lower ratings than did the other residents on items measuring knowledge and skills, but the observed differences were not statistically significant except on one item dealing with the quality of relationships with patients. The residents who had academic difficulties were rated significantly lower than their counterparts on this dimension.
Other empirical findings suggest that measures of postgraduate competence include both cognitive and noncognitive dimensions (Hojat, Veloski, & Borenstein, 1986). Further, a noncognitive factor--interpersonal relationships--has been found to be a better predictor of further residency offers than is a cognitive factor--data gathering and processing skills (Hojat, Borenstein, & Veloski, 1988). Kupfer and colleagues (1978) report that measurements of academic achievement and personality style represent a better approach to predicting which medical students will make better clinicians. Render and Jackson (1972) reported similar findings for students in veterinary school. Gough and Hall (1975), in a study of predictors of who would and who would not graduate from medical school, found that personality measures and academic ability together were the best predictors. Weston and Dubovsky (1984) reported that medical students who had emotional problems in medical school were rated lowest in the areas of postgraduate c ompetence.
Williams (1979) reported an association between personality measures and vocational choice in medical students, and Murden and colleagues (1978) suggested that taking into consideration the personal characteristics of medical school applicants can increase the prediction of success in the clinical years. Reinhardt and Gray (1972), and Yufit, Pollack, and Wasserman (1969) reported that personality is a salient factor that should receive more attention in the socialization of medical students and physicians. Levinson (1967) suggested that both personality and situational factors should be studied in medical education. Linn and Zeppa (1984) found that externality in locus of control and lower self-esteem affect medical students' perception of stress, and Huebner, Roger, and Moore (1981) spoke of dysfunctional stress and its disturbing effects on medical students' performance. All the aforementioned studies suggest that psychosocial attributes are important in predicting the performance of medical students and ph ysicians.
One issue in psychosocial research in medical education is the difficulty of identifying appropriate attributes. The other issue is that most of the instruments that have been developed to measure discrete aspects of personality and psychosocial characteristics are usually time consuming to administer. The relationship between psychosocial characteristics and professional effectiveness is a complex one, and probably could be best explained not by a single measure, but by a combination of variables.
The issue becomes more complex when cross-cultural factors are examined (Guillemin et al., 1993; Geisinger, 1994) in relation to academic and professional achievement in medical school and beyond. Therefore, it would seem desirable to study a number of variables for in-depth investigation of their potential value in predicting academic and professional success within a culture and between cultures. In order to ultimately determine the value of psychosocial attributes for predicting performance in a cross-cultural study, there is a need to find a set of common variables useful in both cultures. For that purpose, it is important to address two issues.
First, can we identify a set of psychometrically sound instruments to be culturally adapted (Guillemin et al., 1993; Geisinger, 1994; Werner & Campbell, 1970) and to be used in an efficient manner to portray the student's psychosocial profile in different cultures? Second, are there some significant differences among medical students from the same culture (intracultural differences), or among medical students from two different cultures (intercultural differences)?
The first important step in answering these questions is to provide evidence in support of the psychometric properties of the measuring instruments in the cultures in which they are intended to be used as predictors of academic success (culturally adapted measures as described by Brislin, 1970; Geisinger, 1994; Guillemin et al., 1993; Werner & Campbell, 1970). The second step is to examine the intra- and intercultural similarities and differences on personality profiles, and the third step is to examine the validity of personality measures in predicting clinical performance of medical students and physicians in different cultures, in the search for common and specific predictors in different cultures.
Evidence in support of construct validity and reliability of a set of psychosocial measures administered to medical students (Hojat, Erdmann, Robeson, Damjanov, & Glaser, 1994; Hojat et al., 1999) and students in other health professions in the United States (Hojat & Lyons, 1998) has already been reported. Because it is our intent to employ these psychosocial measures in longitudinal studies of medical students in Argentina, we designed the present study to examine the psychometric soundness of the instruments in the Argentine culture, and to make some intra- and intercultural comparisons of the results. Therefore, this study follows earlier contributions to the investigation of how psychosocial measures may be used to predict clinical and professional performance (Hojat, Glaser, & Velosky, 1996; Hojat & Lyons, 1998; Hojat et al., 1993; Hojat, Vogel, Zeleznick, & Borenstein, 1998).
This study was designed to investigate the intra- and intercultural similarities and differences in psychosocial profiles of male and female medical students in Argentina and in the United States, and to examine the psychometric properties of the set of culturally adapted psychosocial measures used in this study with medical students in Argentina. The ultimate goal of the project is to investigate the contribution of the culturally adapted psychological measures in predicting performance of medical students and physicians, and their professional preferences and activities, in different cultures. The study is continuing to accomplish that purpose (Hojat, Glaser, & Veloski, 1996; Hojat & Lyons, 1998; Hojat, Vogel, Zeleznik & Borenstein, 1998; Hojat et al., 1999).
Two groups of subjects participated in the study. Group I consisted of 623 American medical students (416 men and 207 women) at Jefferson Medical College of Thomas Jefferson University in Philadelphia, Pennsylvania, United States (U.S.), and Group II comprised 421 students (254 women and 167 men) from the medical school of the University of El Salvador, in Buenos Aires, Argentina. Both medical schools are private. In terms of sex composition, it is interesting to note that the proportion of women was 60% for the Argentine sample, and 33% for the U.S. sample.
Eight psychosocial measures were employed in the present study. To avoid administering lengthy instruments and to increase the response rate, we used abbreviated versions by selecting 5 items from each of the research instruments described below. In addition to searching for content relevancy for college students, we made every effort to select items with better psychometric characteristics based on available data (e.g., a higher item-total score correlation) and based on the psychometrics reported in previous studies with college students (Hojat, 1996, 1998; Hojat, Erdmann, Robeson, Damjanov, & Glaser, 1994). The abbreviated scales were as follows.
1. Perception of Stressful Life Events: participants' own appraisals of selected stressful life events were measured. Five stressors (death of a close family member, personal injury or illness, change of health of a family member, financial problems, and academic problems) were listed; and participants were asked to indicate to what extent each event affected them if it had occurred in the past 12 months (1 = affected a little, 5 = affected a lot, 0 = did not occur). With the exception of academic problems, the items on this scale were selected from the Social Readjustment Rating Scale developed by Holmes and Rahe (1967).
2. Test Anxiety Scale (Sarason, 1972): measures the extent of perceived anxiety when taking a test.
3. Manifest Anxiety Scale (Taylor, 1953): a measure of trait anxiety.
4. UCLA Loneliness Scale (Russell, Peplau, & Cutrona, 1980): a measure of the intensity of loneliness.
5. Rosenberg Self-Esteem Scale (Rosenberg, 1965): a measure of self-acceptance, an aspect of self-esteem.
6. External Locus of Control Scale (Rotter, 1966): measures the extent of attributing the cause of events to external and uncontrollable sources.
7. Extraversion Scale of the Eysenck Personality Questionnaire (EPQ) (Eysenck & Eysenck, 1978): a measure of sociability in interpersonal relationships.
8. The Neuroticism Scale of the EPQ (Eysenck & Eysenck, 1978): a measure of emotionality.
Data for medical students in the U.S. that support the psychometric characteristics of these instruments, including construct validity, internal consistency aspect of reliability and test-retest reliability in medical students and those in other health professions (nursing, rehabilitation, and laboratory sciences), have been reported (Hojat, 1996, 1998; Hojat & Lyons, 1998; Hojat et al., 1994; Hojat, Glaser, Xu, Veloski, & Christian, 1999).
The English versions of the aforementioned instruments were translated into Spanish at the Center for Interdisciplinary Investigation of Mathematical and Experimental Psychology, and the accuracy of the translation was verified by back translating the tests from Spanish to English (Brislin, 1970; Werner & Campbell, 1970; Geisinger, 1994; Guillemin et al., 1993). The research instruments were administered to the students at the beginning of their medical education. A cover letter explained the purpose of the study as investigating the extent of the contributions of psychosocial measures to academic performance and to other medical education outcome measures (Hojat, Gonnella, Veloski, & Erdmann, 1996).
Participation was voluntary, and the students were given sufficient time to complete the questionnaire. The respondents were assured of the strict confidentiality of their responses. Similar procedures were followed in administering the instruments to students in the United States and in Argentina.
The following analytical techniques were applied: (a) comparison of the latent structures underlying each sample by means of factor analysis and varimax solutions, and for intra- and intercultural comparisons, (b) difference between mean vectors using Hotelling [T.sup.2] statistics, and simultaneous confidence intervals at the 5% level. Though in all cases a promax solution was conducted, for purposes of presenting a simpler factor structure and interpretation, we preferred to use a varimax solution.
RESULTS AND DISCUSSION
Intracultural Comparisons of Personality Profiles
In examining the intracultural similarities and differences, we compared the personality profiles of men and women within each culture. The profiles are constructed based on the magnitudes of the means for each personality measure. The personality profiles for men and women in Argentina are depicted in Figure 1.
Inspection of the profiles in Figure 1 indicates that the personality profiles are very similar in male and female medical students in Argentina, with one exception. Argentine female medical students scored significantly higher than their male counterparts on Test Anxiety.
Personality profiles for men and women in the United States are depicted in Figure 2. Again the personality profiles are very similar with the exception that women scored significantly higher than men on General Anxiety and on Perception of Stressful Life Events.
We calculated the effect size estimates for the statistically significant gender differences in Argentine and U.S. samples. The magnitudes were moderate (< .50), and according to Cohen's (1987) operational definitions, none was clinically important. Therefore, the results of intracultural comparisons indicate more similarities than differences in personality profiles between men and women within each culture, and the few statistically significant gender differences were not of practical importance. These results are consistent with our previous findings (Hojat et al., 1999).
Intercultural Comparisons of Personality Profiles
Because the intracultural differences on personality profiles were not of practical importance, we combined data for men and women within each culture, and compared the personality profiles of medical students in Argentina and the U.S. Personality profiles constructed from data for a total of 421 medical students from Argentina and 623 from the U.S. are presented in Figure 3.
Statistical analyses indicated that differences between Argentine and U.S. medical students were significant for all measures used in this study with the exception of the Self-Esteem scale. Argentine students obtained a significantly higher average score than their counterparts in the U.S. on General and Test Anxiety, Neuroticism, External Locus of Control, and Perception of Stressful Life Events. The U.S. medical students were lonelier and less extraverted than their counterparts in Argentina. To examine the clinical significance of the findings, we calculated the effect size estimates (Cohen, 1987). These estimates were small (< .35) for the Stressful Life Events, Locus of Control, Extraversion and Loneliness scales, and moderate for the General Anxiety (.68), Test Anxiety (.54), and Neuroticism (.50) scales.
Psychometric Properties of the Psychosocial Scales
Underlying constructs. Factor analysis of the measuring instruments is recommended to ensure that the culturally adapted instruments have a similar underlying construct in different cultures (Ben-Porath, 1990; Geisinger, 1994). Factor analyses were conducted in order to determine the underlying structure of the measures used in the different cultures. In all cases, two factors were needed to explain at least 80% of the variance, and only factor loadings greater than .30 were considered. Results are presented in Table 1.
As shown in Table 1, the loadings defining Factors 1 and 2 show a striking similarity when comparing the results for men and women in both countries. Bipolar Factor 1, as shown in Table 1, is almost exactly the same for the samples of men and women in both cultures and is defined by Self-Esteem and Extraversion on the positive pole, and by Loneliness and General Anxiety, to which is added Neuroticism in the U.S. sample, on the negative pole. This defined what may be considered to be a basic pattern common to all the factor analyses shown in Table 1. This basic pattern relates to the degree of social communication and may be identified as self-other relations.
Examining the results corresponding to the Argentine sample, it was found that General Anxiety and Perception of Stressful Life Events loaded negatively for men but not for women, thus suggesting an association between Loneliness, General Anxiety, and Life Events for this group.
The loadings that define Factor 2 also show similarities in terms of Test Anxiety, General Anxiety, and Neuroticism, to which is added Self-Esteem for both men and women in the Argentine sample. An interesting finding is the negative loading in Locus of Control for men in the Argentine sample.
Because of the findings that Text Anxiety, General Anxiety, and Neuroticism had significant factor loadings for all samples, Factor 2 may be identified as an emotional instability factor. Examining the patterns and similarities across factor loadings for men and women in the Argentine and the U.S. samples, and within the limitations inherent to our data, it is possible to suggest that in terms of the latent factor structures, the personality measures used in the present study have a common underlying construct.
This supports the construct validity of the personality profile measures in the two cultures and in different sexes. The results of factor analyses generally suggest that the basic pattern of relations, or the characteristics of latent structures, when examined in terms of gender (intraculturally) and in terms of country (interculturally) are essentially the same, hence supporting the construct validity of the measuring instruments.
Reliability. We calculated the internal consistency aspect of reliability (coefficient alpha) for each measure used in this study. These reliability coefficients ranged from a high of .77 (for the Loneliness scale) to a low of .19 (for the Stressful Life Events scale), with a median of .63. We did not expect to obtain a high internal consistency coefficient for the Stressful Life Events scale because not all of the stressful life events had occurred for all of the subjects. Although the reliability coefficients are not very high, they are at an acceptable level considering the length of each scale (5 items). The lower alpha reliability, an index of internal consistency of the scale, is a function of uni- or multifactorial structure of the scales. In other studies we found that, as expected, the multifactorial scales (e.g., Stressful Life Events, Locus of Control) had lower internal consistency estimates than did unifactorial measures such as the Anxiety and Loneliness scales (Hojat et al., 1994, 1998). The pa ttern of these reliability coefficients is very similar to that obtained in another study with U.S. medical students (Hojat et al., 1994).
The results of this study generally suggest that while statistically significant differences in personality profiles exist between samples of medical students in Argentina and the U.S., the underlying constructs of the personality measures are not drastically different in the two countries. In other words, the construct validity of the personality measures used in the present study is relatively stable across the two different cultures.
In addition to the construct validity, we examined the alpha reliability estimates of the personality measures used in the Argentine sample. The findings were very similar to those obtained with students in medical and other health professions in the U.S. (Hojat et al., 1994; Hojat & Lyons, 1998; Hojat et al., 1999).
It is important to note that admission to medical school in the U.S. relies heavily on past academic achievement, knowledge, and cognitive abilities, with less weight given to the psychosocial attributes of the applicants. Although admissions interviews are intended to detect any deficiency in the applicant's personality, due to his or her interest in concealing any such deficiency and other variables, it is quite difficult to assess personality attributes reliably in the brief time available for the admission interview.
These and other findings suggest that a set of psychosocial attributes, such as those investigated here, could profitably be considered as possible predictors of academic performance in medical school (Hojat et al., 1988, 1992, 1993), as well as the clinical competence of physicians (Hojat et al., 1996). Other research has linked these psychosocial attributes not only to academic performance but also to students' physical and mental well-being (Hojat, Gonnella, Erdmann, & Veloski, in press). Given the trend toward greater globalization, it is important and timely to further study the predictive validity of psychosocial measures for academic and professional performance in medical school and beyond in culturally diverse groups. In such cross-cultural studies, we can determine the significant predictors of academic and professional performance that are common to both or specific to each culture. This line of investigation into the extent to which psychosocial measures are predictive of physicians' academic succ ess and their professional behavior in different cultures is of critical importance as national boundaries take on less importance, and as the standards of quality become more universally similar.
Table 1 Rotated Factor Loadings of the Eight Psychosocial Measures by Gender and Country Factor 1 Argentina United States Men Women Men Women Loneliness -.62 -.71 -.66 -.61 Extraversion .57 .69 .72 .32 Self-Esteem .49 .57 .61 .62 General Anxiety -.31 -.41 -.42 Test Anxiety Neuroticism -.41 -.47 Locus of Control Stressful Events -.38 Factor 2 Argentina United States Men Women Men Women Loneliness Extraversion Self-Esteem .38 .35 General Anxiety -.64 -.70 -.70 -.60 Test Anxiety -.51 -.60 -.71 -.67 Neuroticism -.69 -.60 -.59 -.56 Locus of Control -.55 Stressful Events Note. Factor loadings greater than /.30/ are reported. Figure 1 Personality Profiles of Male (n = 167) and Female (n = 254) Medical Students in Argentina Mean Score Personality Measures men women Self-Esteem 16.5 15.8 Extraversion 15.3 15.2 General Anxiety 15.0 16.2 * Test Anxiety 13.9 15.7 Neuroticism 12.5 12.7 External Locus of Control 11.5 11.4 Loneliness 8.6 9.1 Perception of Stressful Life Events 5.2 5.7 Note. Means for men are in bold italic. * Gender difference is statistically significant (P < .05). Note: Table made from line graph Figure 2 Personality Profiles of Male (n = 416) and Female (n = 207) Medical Students in the United States Mean Score Personality Measures men women Self-Esteem 16.5 16.1 Extraversion 14.2 14.6 *General Anxiety 12.9 14.3 Test Anxiety 12.9 13.7 Neuroticism 11.5 11.9 External Locus of Control 10.7 10.9 Loneliness 11.0 10.4 * Perception of Stressful Life 3.8 4.9 Events Note. Means for men are in bold italic. * Gender difference is statistically significant (p < .05). Note: Table made from line graph Figure 3 Personality Profiles of Medical Students in Argentina (n = 421) and the United States (n = 623) Mean Score Personality Measures USA Argentina Self-Esteem 16.4 16.0 * Extraversion 14.3 15.3 * General Anxiety 13.4 15.6 * Test Anxiety 13.2 15.0 * Neuroticism 11.3 12.6 * External Locus of Control 10.8 11.5 * Loneliness 10.8 8.9 * Perception of Stressful Life 4.2 5.5 Events Note. Means for USA are in bolt italic. * Cross-cultural difference is statistically significant (p < .05). Note: Table made from line graph
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This study was supported in part by a grant from the Consejo Nacional de Investigaciones Cientificas y Tecnicas (CONICET), and Universidad del Salvador de Buenos Aires, and Jefferson Medical College of Thomas Jefferson University.
Horacio J. A. Rimoldi and Roberto Raimondo, Center for Interdisciplinary Investigation of Mathematical and Experimental Psychology (Centro Interdisciplinario de Investigaciones en Psicologia Matematica y Experimental, CIIPME), Buenos Aires, Argentina.
James B. Erdmann and Mohammadreza Hojat, Center for Research in Medical Education and Health Care, Jefferson Medical College of Thomas Jefferson University, Philadelphia, Pennsylvania, U.S.A.
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