Abstract:
The fear of being exposed as a fraud as expectations and responsibility increase, considered the sine qua non of imposter syndrome, appears to preclude some physicians from seeking, attaining, and maintaining positions of practice leadership. Despite objective evidence of their competence, physicians with imposter syndrome are convinced they are fakes who do not deserve the success they have achieved. Overcoming imposter syndrome is difficult but not impossible. Cognitive reframing exercises and psychotherapy can be useful in mitigating the impact of imposter syndrome and allowing physicians to realize their full potential as clinicians and leaders. Discussions about imposter syndrome should be integrated into medical student and residency wellness programs and initiatives. The prevalence of imposter syndrome in the physician community and effective support to assist with leadership development deserve further study.
The impostor phenomenon (IP), also known as imposter syndrome, was first described in 1978(1) by psychologists Clance and Imes. It was defined as an internal experience of intellectual phoniness in high-achieving women who seemed to be unable to internalize and accept their success. These women believed each new task would expose them as frauds, and they found countless ways to discredit their accomplishments despite receiving positive feedback from their mentors and peers.
Dr. Clance explains her interest in imposter syndrome on her web site (www.paulineroseclance.com/impostor_phenomenon.html ):
I experienced IP feelings in graduate school. I would take an important examination and be very afraid that I had failed. I remembered all I did not know rather than what I did. My friends began to be sick of my worrying, so I kept my doubts more to myself. I thought my fears were due to my educational background. When I began to teach at a prominent liberal arts college with an excellent academic reputation, I heard similar fears from students who had come for counseling. They had excellent standardized test scores, grades and recommendations. One of them said, “I feel like an imposter here with all these really bright people.” In discussing these students, Dr. Suzanne Imes and I coined the term ‘Impostor Phenomenon’ and wrote a paper on the concept.
Overview
Imposter syndrome has been observed in many types of professionals, but it is especially prevalent in high-stakes professions including business, law, and medicine. Many people experience symptoms for a limited time, such as in the first few weeks of a new job. For others, the experience can be lifelong. Although many studies have focused on women, research suggests that age and gender do not affect the likelihood of experiencing imposter syndrome.(2)
Doctors who exhibit imposter syndrome display symptoms common to those of other professionals, such as anxiety, depression, shame, and burnout. In rare instances, suicide may result.(3) I struggled with imposter syndrome during medical school and most of my residency. It wasn’t until I became chief resident that I realized I had the skills and acumen to be a “real” doctor. The weight of self-doubt was lifted largely by two things:
An argument I won with a senior physician over the treatment of a patient—proof that I had finally “arrived”; and
Psychotherapy with a skilled psychiatrist during my residency. He made a point of telling incoming students: “You all belong here. You can and will become medical doctors.”(4)
Causes
Symptoms of imposter syndrome are believed to stem primarily from prolonged isolation and stress and an inability to meet self-imposed standards of achievement in individuals typically characterized as perfectionists and “type A” personalities,(5) a category that encompasses most medical professionals. It is important to note, however, that imposter syndrome does not necessarily equate with low self-esteem or a lack of self-confidence. The dominant theme is chronic self-doubt and a sense of intellectual fraud that override any feelings of success or evidence of competence.
Approximately one-third to one-half of medical residents have been identified as having imposter syndrome.
Prevalence rates of imposter syndrome in medical professionals vary widely, encompassing 22% to 60% or more of physicians and physicians in training.(6) The sheer prevalence was emphasized by a surgeon who commented, “I’d like to meet someone who hasn’t experienced imposter syndrome.”(5) In this vein, imposter syndrome has been compared to burnout syndrome: both constitute “a problem to be confronted at the organizational level with serious engagement from leadership and investment in both cultural transformation and policy change.”(5)
In 2016, Villwock et al.(7) found that almost a quarter of male medical students and nearly half of female students experienced imposter syndrome. Approximately one-third to one-half of medical residents have been identified as having imposter syndrome.(8,9) Even seasoned clinicians, those at advanced stages in their careers, have questioned the validity of their achievements and reported feelings of imposture. Some believed they had “risen to the level of their incompetence,”(10) suggesting that past accolades could not buffer their insecurities, which they rarely shared with colleagues.
Consequences
A robust literature describes how the negative association between imposter syndrome and job satisfaction and performance results in setbacks in the careers of some individuals and forces others to abandon their profession altogether. Manifestations of imposter syndrome that may adversely impact physicians include a lack of courage to take on new professional challenges, accept new assignments and projects, and learn new skills. Table 1 lists common features of imposter syndrome that interfere with effective practice leadership.
Physicians with imposter syndrome may have significant difficulty suppressing perpetual feelings of inadequacy.
Physicians may harbor symptoms of imposter syndrome as early as medical training (as I did), or when starting their career. LaDonna and associates(10) observed that some physicians believe it’s only a matter of time before they’re “found out.” Whether young or old, physicians with imposter syndrome may have significant difficulty suppressing perpetual feelings of inadequacy, and they often struggle silently in medical practice, without a support system or peer to confide in.(11)
A Better Understanding
One way to better appreciate the impact of imposter syndrome on physicians and their professional development is to hear directly from those affected by imposter syndrome at progressive stages of training. I was able to find representative comments online shared by medical students, residents, and physicians. Here is a small sample of their accounts:
Medical Students
I distinctly remember my first medical school interview. After traveling four hours in a car and changing in a McDonald’s bathroom, I sat anxiously in my suit as other interviewees gathered around me in the lobby. I was nervous about making a good impression, so I tried to focus on chatting with the people around me to distract myself. When our first session began, we were asked to diagnose a patient as a group. I was paralyzed in my seat. Others were scrambling over each other in an attempt to make a contribution and impress the professors. I, however, could not bring myself to utter a word. This is it, I thought, I would not be able to make it in medical school.
During my second-year clinical skills course, an oncologist asked me to identify a rash. “Mycosis fungoides!” I blurted out, since it was one of the few rashes whose name I knew and the only one associated with cancer. My answer turned out to be correct, causing three jaws to drop at once—the oncologist’s, the patient’s, and my own—but the glow of validation lasted barely the rest of the day.
I remember walking the halls and seeing people studying intently, drawing out information on white boards and the glass walls of each study room, as if they were decoding a conspiracy. I felt like an outsider; somehow, I didn’t belong. I felt like a dull crayon in a box of sharps. There was something they knew that I didn’t. Surely everyone was a master at biochemistry except for me. It ate away at me, and I was almost convinced I couldn’t be successful.
Residents
I have suffered from imposter syndrome for longer than I have had a name for the experience. As a member of a high-achieving family, I was never a stranger to academic success. Although I regularly graduated at the top of my class, I can’t say it ever really sank in that I was a well-accomplished person. Perhaps my endeavor to remain humble worked against me; I wanted to avoid taking on any traits of haughtiness, which limited my ability to fully step into my identity without doubt. Throughout my early education, I often worried that I was simply lucky to have been recognized for my good work, that I had slipped through the cracks. I felt like I had to keep up the illusion that I was smart, lest I slip up and reveal the opposite. I never dwelled too much on these thoughts, and I like to think I never let them affect my performance—but they were always there nevertheless.
My gratitude at having matched at such an esteemed program became a major source of my self-doubt. I questioned everything. Did I deserve to train [there]? Why had they chosen me? When would they realize they’d made a mistake? The fear of being exposed as the fraud I felt I was did not make me a better physician or resident. My faculty mentor said it best: “When you believe that everything is a weakness, you cannot make steps to improve your actual deficits.”
I thought I must have just gotten lucky because there was no way [the board exam] was a true assessment of my knowledge. Looking back on it, I didn’t have the confidence to say, “I did deserve that,” and give myself credit.
I remember a night on call in my second year of residency when I ignored an overhead page because I could not believe I was the physician being called to attend a resuscitation. Unfortunately, it was not a mistake. I must have accomplished the resident record for fastest dash to the emergency department. I felt a deep sense of inadequacy and self-doubt during my residency training.
I remember the first time I was in charge of a “code”— the moment a patient died—realizing that the only potential antidote to this state was...well, me. The responsibility of that was simply indescribable. To grapple with potential finality—death itself beckoning in its victim—as you thumped on his chest, pleading him to stay, then feeling the lowest of lows as you “pronounced” defeat. If you weren’t an imposter before, you were clearly one now. More than ever.
Physicians
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!”
I had this feeling [of being an imposter] when I made it into college, then again in medical school. Even when I got out into practice, taking care of patients, I had that fear. Part of me was in awe of how far I had come, but the voice inside would tell me: “They are going to find you out. You are a fraud.” But not because I really was—I legitimately studied, got the good grades, got the good test scores, impressed my attending surgeons, aced the interviews, and made my way into medical school, residency, fellowship, and beyond. But this fear was still there and would occasionally rear its ugly head. It never quite goes away...
I used to have a recurring dream that centered around a sudden realization that I still hadn’t passed my final fellowship exam. I would wake up truly believing for a few moments that despite all I had done, I still hadn’t been successful. When I reflect back on this, and the many years it took for that dream to pass, I recognize that it was a manifestation of self-doubt in my abilities as a doctor.
There are invisible gates or wormholes to better career possibilities. Having imposter syndrome means you will miss the gate when someone asks you if you’re ready or interested in something.
Professional Development
Trainees and physicians with imposter syndrome may feel unprepared for the next stage of their careers or future job prospects. Physicians plagued by imposter syndrome, particularly those with misplaced self-doubt who are unable to accurately assess their skills and abilities and are unreceptive to corrective feedback, tend to become less motivated and productive over time. They display self-handicapping behaviors such as procrastination and perfectionism. Perfection has been declared the enemy of success, whereas a growth mindset is its greatest friend.(12)
Unfortunately, victims of imposter syndrome are robbed of their growth potential.
When a physician feels like a phony, it can create a ripple effect. A physician’s drive to pursue prestigious residencies, fellowships, or promotions may be thwarted by an inner voice that tells them they’re not qualified and would not be selected. Doctors who believe they are imposters may behave in such a way as to cut short their potential to become physician researchers and educators. Chandra and colleagues(13) have candidly asked whether imposter syndrome could be the reason why some promising physicians appear to have unfulfilled talent and are “held back” in their careers.
Despite significant achievements, physicians with imposter syndrome often aim low in order to limit their visibility lest others detect their (imagined) fraudulence.
It’s been said that imposter syndrome doesn’t affect a person’s ability to shoot, but it affects where they aim. This means that from a career perspective, despite significant achievements, physicians with imposter syndrome often aim low in order to limit their visibility lest others detect their (imagined) fraudulence. Their careers become truncated by mental paradigms that dictate “I am a failure,” “I am a fake,” and “I am not successful.” In the mind of an imposter, success is the result of chance, and good luck will surely run out. Imposters pass up significant career opportunities because they are convinced they won’t be able to do better elsewhere.
Specific Leadership Issues
One of the founding tenets of the American Association for Physician Leadership is that all physicians are leaders at some level.(14) However, physicians with imposter syndrome may avoid prominent leadership opportunities and fail to reach their full potential because the additional responsibility and visibility that comes with a leadership role intensifies their performance anxiety. In short, physicians with imposter syndrome may be passed over for leadership positions, use flawed logic to exclude themselves from consideration, or fail as physician leaders.
Indeed, strong leaders are self-actualized, which is to say they have a keen sense of their aptitudes and skills and strive to reach their full potential. Physicians with imposter syndrome, however, downplay their capabilities and hesitate to fully utilize their potential. They represent the antithesis of self-actualized individuals as originally described by the psychologist Abraham Maslow(15) (Table 2).
Furthermore, physicians with imposter syndrome live in constant fear of making mistakes, which is incompatible with exercising strong leadership. All leaders make mistakes, have the courage to admit it, and are willing to learn from their mistakes. Moving on unfettered by mistakes and maneuvering through a minefield of potential errors is the norm for physician leaders. Physicians with imposter syndrome would likely feel extremely uncomfortable working under those conditions.
Leading by authority presents a special challenge for physicians who have imposter syndrome. Many physicians tend to lead by example and expert authority, so-called “servant leadership”(16) — where a physician’s unique and extensive knowledge of diseases and therapeutics, and of human nature, serves as the basis of their authority and the platform for leading. By definition, however, imposter syndrome causes doctors to feel like fakes rather than experts. Physicians with imposter syndrome may not seek leadership positions because they discount the value of their (expert) opinions and don’t consider themselves genuine leaders worthy of leadership roles.
Management
Overcoming imposter syndrome is not an impossible task. Although imposter syndrome is not a recognized disorder in the Diagnostic and Statistical Manual of Mental Disorders, 5th edition, certain cognitive tools and psychotherapy can be used to overcome it. Although a complete discussion is beyond the scope of this article, Table 3 provides some tips aimed at managing imposter symptoms over time.
For medical students and residents, discussions with insightful faculty have proved highly effective in recognizing and dealing with signs and symptoms of imposter syndrome.(17) Faculty leaders themselves need to be honest about their experiences with imposter syndrome and share their insecurities with students and residents. The prevailing academic culture of blame and shame must be transformed into a culture that nourishes trainees and rewards organizational efforts to achieve psychological well-being in clinicians.
Conclusion
Recognizing that many trainees and newly minted physicians feel like imposters, my advice to them is as follows:
Imposter syndrome is a name only. Don’t let it derail you from your goals and aspirations.
Realize that feelings of inadequacy are normal and ubiquitous among your peers. Don’t be imprisoned by the fear of making mistakes—everybody makes them.
Remember that the biggest misconception about Abraham Lincoln is that he was perfect. Cognitive distortions of your abilities and achievements are just that—distortions, which are correctable.
You are not a fraud. You haven’t gotten this far by accident. You have what it takes to be an excellent clinician and leader.
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Roub M. Mark Cuban was right – “perfection is the enemy of success.” Inflection 360. September 3, 2018. https://inflection360.com/mark-cuban-was-right-perfection-is-the-enemy-of-success/ .
Chandra S, Huebert CA, Crowley E, Das AM. Imposter syndrome: could it be holding you or your mentees back? Chest. 2019;156(1):26-32
Angood PB. All Physicians are Leaders: Reflections on Inspiring Change Together for Better Healthcare. Washington, DC: American Association for Physician Leadership; 2020.
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