By Inas Abuali, MD, FACP
I recently rotated on an inpatient service with a group of medical residents and students. I was very impressed by the knowledge and bedside manners of one of the students and later approached her to give her feedback. She shrugged, looking very uncomfortable, and said, “Thanks. You are being kind.”
Given that uncomfortable deflection is also my personal default response on receiving any form of positive feedback, I insisted on providing her with specific examples of her excellent performance over the past few weeks. She finally said, “I don’t feel like I am doing such a good job. Honestly, I sometimes feel that I am here just because I got lucky.”
Recognizing this all-too-familiar sentiment, I nodded, “Me too!”
This is not an isolated incident but something that I have commonly encountered throughout my 17 years of medical education and practice. Perhaps you, yourself, have felt this way at some point during your medical career. Does positive feedback make you feel uncomfortable? Do you sometimes downplay your accomplishments, attributing them to “being in the right place at the right time”? Do you feel that you are lagging behind everyone else? Is there a pesky inner voice that occasionally whispers, if they only knew I don’t really belong here?
Ironically, as I type this article, I wonder if I am qualified enough to write about this topic!
What is the scope of the problem?
Imposter syndrome (IS) is a recognized phenomenon that has gained public interest over recent years. It was initially described by Clance and Imes in 1978 and is defined as an “internal experience of feeling like an intellectual fraud despite external evidence of an individual’s accomplishments.”1
This is commonly encountered in many high-stakes professions including health care, business, and law. In recent years, multiple public figures have openly acknowledged feelings of imposter syndrome. Facebook’s Sheryl Sandberg shared, “There are still days when I wake up feeling like a fraud, not sure I should be where I am.” Nobel Laureate Maya Angelou admitted that each time she wrote a book, she thought, “Uh oh, they’re going to find out now. I’ve run a game on everybody, and they’re going to find me out.”
The medical literature cites varying prevalence statistics for this phenomenon. In some published papers, self-reported feelings of impostor-ism ranged from 30% among 175 surveyed family medicine residents to 44% among a group of 48 internal medicine residents.2,3
In 2015, LaDonna et al. interviewed 28 physicians about their experiences with underperformance. Many participants, even those in later stages of their career, questioned their achievements and reported their career advancement as “rising to the level of your incompetence.” Furthermore, it was noted that positive feedback could not buffer insecurities and that many were hesitant to discuss their struggles with colleagues.4
There is a paucity of literature regarding solutions for imposter syndrome, which has been linked to the epidemic of physician burnout and growing career dissatisfaction. Burnout has received a lot of attention in recent years with ACGME championing wellness initiatives to mitigate this. While burnout is recognized to be influenced by the external environment, imposter syndrome is still being attributed to individual “defects” such as a “perfectionist nature.” It is true that an association with type A personalities likely exists; however, it is important to acknowledge that imposter syndrome is in large part also brought on by our medical culture that breeds intolerance to mistakes, “tough love,” and workaholic, unrealistic expectations.
What can we do on an individual level to combat imposter syndrome?
The first step is to recognize those feelings and to develop an awareness of what triggers them. This should be followed by an attempt to reframe the emotion in the appropriate context. It is normal to occasionally feel out of your depth in a new situation. Remind yourself of prior circumstances where you had a steep learning curve that you mastered and look upon this as a challenge, knowing that “this too shall pass.”
Remember that others suffer from imposter syndrome as well, so speak openly about it. Studies have shown that sharing these feelings with mentors and colleagues may be an important aspect of coping.5
The simple sentiment of being kind to yourself and to others will go a long way! Be aware that this may be a quiet struggle for others so do not be quick to label people judgmentally. Instead of telling a more junior trainee or colleague to “be confident,” help them realize their strengths via constructive feedback such as specific examples of positive attributes, acknowledging hard work, and reinforcing that the praise is earned. Feedback that is too generalized (“You are a good doctor”) may be attributed to being kind and therefore discounted. Specific objective data is harder to argue with and helps diminish self-doubt over time.
What can we do on an institutional level?
In a paper by Houseknecht et al., students were surveyed throughout their medical school years. It was noted that over time their wellness and feelings of professional identity decreased, while feelings of imposter syndrome increased.6
Is it possible then that our medical culture fosters these feelings of inadequacy? Should this be the time to re-evaluate our medical training environments and shift away from the traditional “shame and blame” model, instead adopting more of a growth mindset? I believe that it is imperative we cultivate a safe space where mistakes are accepted as part of the learning process and turned into teaching opportunities.7
In a recent study by Ramsey et al., educational sessions were held for new medical interns to openly acknowledge feelings of insecurity and self-doubt and encourage an open dialogue.8 There is a growing interest among medical educators in better equipping their trainees with strategies to successfully tackle imposter syndrome to ultimately be able to reach their full potential.
What can we do as a society?
In a recent opinion piece by Mullangi and Jagsi, there is a call to address the underlying root of imposter syndrome by promoting equitable representation of women and minorities in our field and in the leadership of our field. It raises our attention to the fact that this underrepresentation is not an individual failure but rather a system failure, whereby marginalized groups in medicine develop self-learned behaviors that reinforce this vicious cycle of self-doubt due to multiple factors including inherent biases, oversight in promotions, disparity in evaluations, and lack of leadership role models.9
This is to a large extent why imposter syndrome is observed more frequently in women and minorities. In order to remedy this, positive actions need to be implemented to correct the gender and racial biases that exist in the medical field.
In an interview, U.S. Olympic gymnast Simone Biles said, “It’s important to teach our female youth that it’s OK to say, ‘Yes, I am good at this,’ and you don’t hold back. You only see the men doing it. And they’re praised for it and the women are looked down upon for it. But I feel like it’s good (to do) because once you realize you’re confident and good at it, then you’re even better at what you do.”
Let that be the same message we give our medical trainees: a call towards recognizing and owning their accomplishments. Let us help build each other up in a safe environment that recognizes the inevitability of mistakes and transforms them into opportunities for growth.
And if you are currently struggling with feelings of self-doubt, remember that you belong here.
Dr. Abuali is a hematology/oncology PGY5 fellow at the University of Cincinnati Medical Center and a member of the ASCO Trainee Council.
- Bellini MI, Papalois VE. Gender Equity in the Medical Profession. IGI Global, Aug 2019.
- Oriel K, Plane MB, Mundt M. Family medicine residents and the impostor phenomenon. Fam Med. 2004;36:248-52.
- Legassie J, Zibrowski EM, Goldszmidt MA. Measuring resident well-being: Impostorism and burnout syndrome in residency. J Gen Intern Med. 2008;23:1090-4.
- LaDonna K, Ginsburg, S, Watling, C. “Rising to the Level of Your Incompetence”: What Physicians’ Self-Assessment of Their Performance Reveals About the Imposter Syndrome in Medicine. Acad Med. 2018;93:763-8.
- Sanford AA, Ross EM, Blake SJ, et al. Finding courage and confirmation: Resisting impostor feelings through relationships with mentors, romantic partners, and other women in leadership. Adv Women Leadersh. 2015;35:31.
- Houseknecht V, Roman B, Stolfi A et al. A longitudinal assessment of professional identity, wellness, imposter phenomenon, and calling to medicine among medical students. Med Sci Educ. 2019;29:493-7.
- Seritan AL, Mehta MM. Thorny laurels: The impostor phenomenon in academic psychiatry. Acad Psychiatry. 2016;40:418-21.
- Ramsay JL, Spencer AL. Interns and imposter syndrome: proactively addressing resilience. Med Educ. 2019;53:504-5.
- Mullangi S, Jagsi R. Imposter Syndrome: Treat the Cause, Not the Symptom. JAMA. 2019; 322:403-4.