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Imposter Syndrome Among Physicians

Have you ever felt like a fraud, as if your successes are the result of luck, that those successes are “no big deal” or that anyone could have accomplished what you did? I have. If so, you may be suffering from what is termed Imposter Syndrome.

It turns out Imposter Syndrome or Imposter Phenomenon is highly common, and almost all of us have felt this way one time or another. I have. Now, for me not to be an imposter with this editorial, I’ll state at the outset that until I started researching this topic, I had no idea what Imposter Syndrome was. I really learned a lot about it while speaking to a couple of my residents, which triggered this editorial. But after reading about it, I know I’ve suffered from it in the past and sometimes still do. This phenomenon is common in those who have successful professional lives – like healthcare providers. It is also a major driver of physician burnout, which is rampant in today’s medical fields.

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I recall what might be the first time I felt like an imposter: the first day of residency when I donned my long white coat. I remember thinking, “Why is everyone calling me Dr Shapiro when just yesterday I was Jarrod? I don’t really know anything, but they all think I’m a physician.” I also recall this feeling disappearing whenever I was on a podiatric rotation. I guess the familiarity of the specialty I had studied for the prior four years was comforting. In fact, even though I knew I had so much lower extremity medicine and surgery to learn, my ignorance was ok. I was safe.

I’ve also occasionally felt this when asked to speak at various conferences. For example, one of my first speaking jobs was at a regional conference in Los Angeles where I spoke about surgically treating diabetic patients. As is true for almost anything diabetic foot related, I repeatedly cited research by David Armstrong and his colleagues, and thought more than once, “Why didn’t they just ask David Armstrong to speak? He’s the real expert.”

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These thoughts are unproductive at best and potentially dangerous at worst, so let’s educate ourselves about Imposter Syndrome (IS) and discuss ways to combat it.

What is Imposter Syndrome?

This behavioral pattern, first described by Langford and Clance in 1978, occurs when one doubts one’s accomplishments and has a persistent internalized fear of being discovered to be a fraud. Others relate this as an “inability to accurately self-assess with regard to performance” …with “faltering self-confidence, an internalization of failures, and over focus on mistakes over the long term…” The idea of an “inaccurate self-assessment” is key and is the fundamental psychological flaw. Despite actually being successful at what you do, the sufferer from Imposter Syndrome incorrectly thinks they are successful by luck and not as a result of their own hard work and excellence.

According to Valerie Young, EdD, an expert in this subject, a major problem is how people define “competence.” People suffering from Imposter Syndrome hold themselves to an unrealistically high and unsustainable standard of competence. She has also found that because people define competence in different ways, there are five different “Competence Types”.4 These are essentially reactions to the anxiety generated from not feeling good enough.

Competence Types

  1. The Perfectionist – This person defines competence by “how” something is done. One small flaw in an outcome can lead to a definition of failure.
  2. The Expert – The focus is on “what” and “how much” one can do. Competence means knowing everything, so small gaps in knowledge equate to failure.
  3. The Soloist – This is about “who” completes a task. This person must do it all on their own and needing help is a sign of failure.
  4. The Natural Genius – Competence is measured in how easy or fast one learns a skill or subject. If one has to struggle a little to master a subject this person will feel shame.
  5. The Superwoman/Superman – Competence is defined by “how many” roles a person can fill or how many jobs one can get done. Failure in any of the many roles this person takes on may be catastrophic.
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Honestly think about yourself in relation to these types. Do you see yourself in any of these? I see myself as a combination of the expert and the superman. I’m one of those people who at work tends to take on many roles, and I very much focus on maximizing knowledge and struggle against ignorance. Habitually, I’m very much the superman – it’s a part of my personal work ethic to take on simultaneous responsibilities and be the one people rely on. I would describe myself as episodically the expert, where most of the time I have no compunctions with stating my ignorance, while often feeling ignorance will lead to my failure.

I know what you’re thinking. “What’s wrong with being knowledgeable or trying to do something as well as possible or taking on multiple responsibilities?” There’s nothing wrong with any of these, per se. It’s when these actions become responses to a feeling of insecurity and feeling “less than” despite your success that they become problems that can lead to stress, anxiety, depression, and burnout. For a very intellectual and cogent discussion of this aspect, I point you to Sakulku and Alexander’s paper, which discusses the “Impostorism Cycle” and the psychological origins of this problem.5

What are the Risk Factors for IS?

According to Gottlieb and associates, in a systematic review that included 18 papers studying physicians and physicians in training, female gender, low self-esteem, and institutional culture (the general hierarchical nature of medicine) were associated with higher rates of IS.6 Underrepresented minorities are also at risk. However, given the ubiquity of this problem it’s fair to say that everyone is at risk. LaDonna and colleagues found self-doubt to be present in medical clinicians of all levels, from trainees to seasoned providers.3 Additionally, transitions, challenges, and increases in responsibility may also be risk factors.3

How can We Combat Imposter Syndrome?

Gottlieb’s study found a variety of protective factors against IS1 including social support, validating success, positive affirmation, and institutional support.

It is recommended that institutions have workshops on IS, develop mentoring programs, and fostering a culture that does not punish mistakes.1

From a personal standpoint here are some

Suggestions for combating impostorism7

  • Own and celebrate your achievements.
  • Take mistakes in stride and consider mistakes as opportunities to grow.
  • Consider constructive criticism as an opportunity rather than a personal criticism.
  • Remember that your work will never be 100% perfect.
  • Veer away from external validation of your success focusing on internal validation.
  • When an error occurs focus on specific, measurable, and concrete factors you can improve over time.

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Final Thoughts

If you think you may be suffering from Imposter Syndrome, take the Clance Imposter Phenomenon Scale Evaluation. Some other things you can do include finding a mentor or coach willing to foster a productive discussion about this3 and seek out environments where direct observation and constructive feedback are regular activities. A final suggestion is to read Carol Dweck’s book Mindset: The New Psychology of Success, which is an excellent discussion of maintaining a healthy mindset to fight feelings of imposter syndrome.

Best wishes.

Jarrod Shapiro, DPM
PRESENT Practice Perfect Editor
[email protected]
References
  1. Clance PR, Imes SA. The imposter phenomenon in high achieving women: Dynamics and therapeutic intervention. Psychotherapy: Theory, Research & Practice. 1978;15(3):241.
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  2. Parkman A. The imposter phenomenon in higher education: Incidence and impact. Journal of Higher Education Theory and Practice. 2016;16(1).
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  3. LaDonna KA, 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 May;93(5):763-768.
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  4. Young V. The Five Types of Imposters. https://impostorsyndrome.com/5-types-of-impostors/. Accessed Feb 15, 2020.
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  5. Sakulku J, Alexander J. The Impostor Phenomenon. The Journal of Behavioral Science. 2011;6(1):75-97.
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  6. Gottlieb M, Chung A, Battaglioli N, Sebok‐Syer SS, Kalantari A. Impostor syndrome among physicians and physicians in training: A scoping review. Med Educ. 2020 Feb;54(2):116-124.
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  7. Wilding M. 5 Different Types of Imposter Syndrome (and 5 Ways to Battle Each One). The Muse. https://www.themuse.com/advice/5-different-types-of-imposter-syndrome-and-5-ways-to-battle-each-one. Last accessed Feb 15, 2020.
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