The Whole Physician: Addressing Imposter Phenomenon in the Physician Population

During your medical training or clinical practice, have you ever felt like a fraud, as though you were about to be “found out”? Do you constantly compare yourself to your colleagues and feel as though your intelligence and accomplishments will never measure up to theirs? Do you find it difficult to accept your success as a physician, focusing instead on your mistakes? These feelings are indicative of imposter phenomenon (IP). Whether your response to these questions was definitely “yes,” or you find it difficult to imagine any physician answering yes to these questions, you should know that IP is prevalent in the physician population. Experiences of IP directly impact clinical practice and are associated with professional unfulfillment, burnout, and suicidal ideation.¹ Thus, it is crucial to recognize IP and its impact in the physician population. This article focuses on the causes and effects of imposter syndrome and describes practical steps physicians and medical institutions can take to identify and mitigate IP.

Identifying the Causes of Imposter Phenomenon

IP, also known as “imposter syndrome” or “impostorism”, is defined as “feelings of uncertainty, inadequacy, and being undeserving of one’s achievements despite evidence to the contrary.”² Experiences of IP are common in the physician population, and physicians experience IP at a higher rate than other US workers.³ A Mayo Clinic study found that over 58% of 3116 physicians who participated in a 4-item version of the Clance Imposter Phenomenon Scale had scores associated with moderate to intense IP experiences, and between 4% and 10% of participants endorsed each of the items in this scale as “very true” of their experience.¹

Rates of IP are higher in women and in international medical students, and in those practicing in certain clinical subspecialties (ie, pediatrics and emergency medicine).^1,4 Although it is unclear what factors are associated with higher rates of IP in clinical subspecialties and demographic groupings, the causes likely include personality differences, lack of demographic representation in the medical field, and the culture of medical education and the medical profession. The medical field attracts individuals who are driven, competitive, and able to endure high pressure and demanding expectations.⁴ Because medical education includes high standards and strict norms and trainees find themselves surrounded by others who are also accomplished and driven, medical training in itself often contributes to the development of IP.

Not all experiences associated with IP such as self-doubt and uncertainty are necessarily caused by IP. Most individuals experience feelings of uncertainty or inadequacy, so it is important to note the context in which these feelings surface before concluding they are the result of IP. For instance, career transitions and new experiences of any kind can generate an appropriate amount of anxiety and uncertainty. These feelings are okay as long as they do not hinder learning and individual progress. IP is associated with chronic feelings of inadequacy, self-doubt, and shame resulting from unrealistic and unsustainable expectations. Importantly, not all physicians experience failure-related shame the same way, because physicians define competence and success differently. Dr. Valerie Young, co-founder of the Imposter Syndrome Institute identifies 5 types of IP (Table) based on these varied understandings of success.⁵

IP results from a combination of individual and systemic causes. Systemic causes of IP can result from the culture of medical education. The physician training process is demanding and requires confidence and determination. During their training and throughout their careers, physicians are surrounded by gifted colleagues who possess a variety of educational and experiential backgrounds. At the individual level, IP can result when perfectionist tendencies cause physicians to interpret their mistakes as a reflection on their inherent value, ultimately generating the feeling that they are a fraud and about to be “found out.” This can quickly snowball and generate a paralyzing self-doubt, and is exacerbated by the high stakes nature of the medical field in which mistakes are potentially lethal. Mistakes can be a valuable learning tool generating professional progress, but those experiencing IP tend to view mistakes as an embarrassing character flaw related to their professional competence.

The Effects of Imposter Phenomenon

Although there is no formal Diagnostic and Statistical Manual of Mental Illnesses (DSM-5) definition for IP, it is associated with various behavioral health conditions, including anxiety, depression, other mood disorders, burnout, low self-esteem, and personality disorders.⁷ IP can exacerbate these underlying behavioral health conditions and lead to higher levels of professional unfulfillment, burnout, and suicidal ideation.¹ Identification and management of IP are crucial to mitigate these effects and generate positive change in those physicians experiencing IP.

IP has the potential to significantly impact clinical practice. For example, patients may have a difficult time trusting their physician’s diagnosis or advice if the patient receives the impression that their physician lacks confidence. Additionally, some physicians compensate for feelings of inadequacy and self-doubt by working harder, leaving them feeling exhausted and incapable of performing to their full potential. Physicians who experience IP also tend to be internally focused (ie, they have negative internal dialogue and are always thinking about their own inability), which can prevent them from actively listening to their patients and fully dealing with the needs of their patients. Furthermore, physicians who doubt their abilities tend to focus exclusively on practices and techniques they already know or are comfortable with. Thus, they are less likely to experience the professional growth that comes from branching out and attempting new techniques or strategies.

Similar experiences can occur in trainees who compare their skills and experiences to their more experienced mentors. It is easy for trainees to lose perspective in these instances and forget that hidden behind every experienced physician’s CV are numerous failures and hurdles they had to overcome. In other words, difficulties and failure are part of the medical educational journey, but they are often hidden. For example, a trainee who has a mentor that was recently awarded an impressive grant does not see the numerous other grant applications that were not accepted, or the numerous journal articles that were rejected prior to acceptance of the most recent publication. Mentors can prevent these false perceptions in their trainees by being vulnerable and sharing stories of failure with their trainees. Vulnerability and intellectual humility are critical factors that promote educational progress and prevent IP by helping trainees view their education as a journey rather than a yet-to-be-realized destination.

Practical Steps for Combating Imposter Phenomenon

Because not all negative thoughts and self-doubt are the result of IP, how can a physician determine if they are experiencing IP? At the level of the individual, physicians should perform an honest and careful self-evaluation. For a detailed analysis, individuals can complete the Clance IP Scale questionnaire (https://paulineroseclance.com/pdf/IPTestandscoring.pdf).⁸ Common signs of IP include chronic levels of anxiety and depression and feelings of inadequacy.¹ Physicians should also gauge their self-compassion. Physicians experiencing IP often demonstrate compassion for others but are incapable of turning this compassion inward. Additional signs of IP include the inability to accept success or compliments (eg, explaining away the reason one receives an award), never feeling that any level of achievement is good enough, chronic feelings of self-doubt, and consistently reacting to co-worker feedback negatively.

There is not clear consensus on how IP evolves over the arc of an individual’s career trajectory. In academia, while some hypothesize that IP is mitigated with career longevity, accumulation of objective evidence of competence, and development of coping skills, other studies have demonstrated that even faculty at advanced career stages question the validity of their achievements.⁹ It is also important to note that even outstanding performers may struggle, with experiences of transition, challenge, and increased responsibilities as triggers of self-doubt.⁹ These insecurities are rarely shared with colleagues, further emphasizing the need to normalize these experiences. Additionally, much of the existing research to date has been focused on minority and early-career faculty. In addition to the well-established disparities minority faculty face, isolation is a less-studied component of the constellation of external factors that contribute to IP.¹⁰

Physicians experiencing IP should know they are not alone and that these experiences are common in medical practitioners. IP can intensify loneliness by amplifying feelings of isolation and unworthiness, especially in physicians who feel pressure to be right all the time. The US Surgeon General, Dr. Vivek Murthy, recently documented the “epidemic of loneliness” and its association with negative physical and mental health outcomes (eg, stroke, dementia, heart disease, depression, and anxiety).¹¹ As such, physicians should regularly perform self-assessments and seek help if they determine they are experiencing IP. Elevated stress levels can exacerbate the negative thoughts and feelings associated with IP, so individuals can also combat IP by reducing stress levels through proper diet, mindfulness techniques, adequate exercise, and sleep.¹²

Although self-assessment and self-care are critical to treating IP, it is often difficult to overcome IP by oneself. IP is an issue the entire medical community needs to address. Medical practitioners need to be intentional about recognizing and confronting IP. Many physicians who have never experienced IP are shocked to learn their colleagues struggle with IP. This is why IP needs to be addressed in medical training and continuing medical education programs. Medical education should not focus exclusively on revealing gaps in trainee knowledge by emphasizing mistakes and centering on what trainees do not know. Instead, medical education ought to consist of a collaborative journey in which experienced physicians encourage trainees to progress in their medical knowledge and see themselves as co-learners with their trainees. This fosters a culture of collaboration in which mistakes are not regarded as the worst possible outcome, but rather as part of the educational journey designed to strengthen the next generation of physicians. Intentionally incorporating vulnerability and honesty within medical education sheds light on every physician’s limits and imperfections and enables those experiencing IP to deconstruct the false notion that everyone else is perfect.

Some institutions are taking steps to adress IP. For example, recently Stanford University School of Medicine hosted a session on IP for medical students and trainees. The reactions of those in attendance highlight the importance of sessions like these. After attending this seminar and reflecting on her experience running a search committee, Dr. Lisa Chamberlain remarked, “We could have done a better job in involving junior faculty in our search committee…Inviting them to be involved in an important hiring decision would have sent the message that ‘We trust your voice. You belong there.’”¹³ The University of Kansas is bringing awareness to IP by including the topic in its introductory seminar series for medical students. Efforts such as these will normalize experiences of IP and help physicians recognize and mitigate IP earlier in their careers.

Harvard Medical School Faculty, Physician Coach, and Certified Mindfulness Teacher, Gail Gazelle, MD, has a free resource on IP available at https://gailgazelle.com/imposter/