In the current climate of emphasizing physician mental health, it is important for teachers and learners alike to better understand impostor syndrome. Most physicians can recall a time during their training when they felt unworthy of the privileges and responsibilities given to them. I remember a night on call in my second year of residency when I ignored an overhead page for “Dr Chen” 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, and it took many displays of affirmation from preceptors and peers to help me gain confidence in my abilities.
Also called impostorism or the impostor phenomenon, this concept was first described by psychologists Clance and Imes in 1978. The term describes a constellation of symptoms characterized by “chronic feelings of self-doubt, the fear of being discovered as an intellectual fraud, a perception of being less intelligent or competent than peers, and an inability to internalize a sense of competence of skill in high-achieving individuals.”1 Impostor syndrome has been described across various professions and in both male and female sexes but tends to be more prevalent in women and minority groups.
Prevalence of impostor syndrome in health care
Impostor syndrome has been well documented in the health care profession. Approximately 30% of medical students and residents identify as impostors, with higher rates among women and international medical graduates.2–5 Impostor syndrome tends to rear its head at the beginning of new jobs, new projects, or new careers.6 Even experienced physicians are not immune and might struggle despite receiving positive feedback from peers and patients.7 As teachers and mentors, it is important to identify and support learners most at risk of burnout, before their academic and professional performance is affected. As impostor syndrome can be thought of as a risk factor for burnout and psychological distress,4,5 it is crucial that we familiarize ourselves with its features (Box 1).6
Features of impostor syndrome
Does this sound familiar?6
Inability to accept or internalize one’s success
Tendency to attribute one’s success to luck or chance rather than to one’s own ability
Difficulty accepting praise about one’s intelligence or accomplishments
A discrepancy between one’s self-evaluation and external evaluations
A fear of being revealed as a “fraud”
Tendency to recall mistakes over accomplishments
Disappointment with present accomplishments
Hesitancy taking on new challenges for fear of failure, despite previous success
Making frequent comparisons to others, believing others are more accomplished
A reluctance to disclose potential promotion until it is accomplished
How to address impostor syndrome
If impostor syndrome is so prevalent (or expected), what can and should we do about it? There is a dearth of evidence on what strategies or interventions are most helpful and, certainly, more research is required. After presenting on this topic as a resident and again as a new staff member at our multidisciplinary family practice rounds, I informally polled my colleagues and gleaned some important themes on how to address this issue.
First, we should anticipate impostor syndrome in our learners, especially those undergoing important life and career transitions (eg, beginning of clerkship, beginning of residency, after graduation). Learners might not know that their feelings are commonly felt by others and might be reluctant to disclose these feelings for fear of negative social and academic repercussions.8 Teachers can help by normalizing these feelings and providing reassurance that residents are not alone in their experiences. As a learner, I found it very helpful to hear my role models, residents, and preceptors share that they, too, battled impostor syndrome.
Second, we should encourage reflection, both structured and unstructured. Longitudinal mentoring or teaching relationships are excellent opportunities to debrief experiences with learners in a safe space. Clance and Imes suggest applying psychotherapeutic principles to help learners understand their own impostor syndrome responses and reframe the way they interpret their experiences.1 It might also be beneficial to intentionally include impostor syndrome in wellness curricula, whether through peer support groups (eg, Balint groups, social media forums) or planned reflective opportunities during academic teaching (eg, journaling, workshops, grand rounds). Formal screening with the Clance Impostor Phenomenon Scale could be considered during formal undergraduate or postgraduate medical education evaluation. We, as teachers, should also reflect on our own experiences with impostor syndrome—could the fear and anxiety we might have experienced as trainees contribute to a cycle of not sharing our insecurities and uncertainties with learners?
Third, we should optimize our feedback for the needs of the current generation of trainees, who prefer immediate and specific evaluation.9 Trainees with impostor syndrome might struggle with identifying general negative feedback as critiques of certain skills, and might see this as confirmation of their impostorism. Conversely, nonspecific positive feedback might be seen as evidence that they continue to “fool” people—that their deficiencies have once again flown under the radar.1 We should also be aware that there might be large discrepancies between a learner’s perceived and objective performance. Dunning and Kruger describe how some learners can be blind to their own poor performance and rate themselves highly on self-assessments.10 On the other hand, impostors can be blind to their own excellent performance and rate themselves negatively on self-assessments. Thoughtful feedback provides a mechanism for learners to recalibrate their perceptions of performance.
Conclusion
Ultimately, more research is needed on how best to identify those experiencing impostorism and those at highest risk of burnout or mental health distress. We are also still learning the most effective ways to support those combating impostor syndrome. We must continually evaluate our medical culture to promote learning environments and workplaces that value both physician well-being and excellence in patient care. It is possible to create cultures of encouragement, openness, and growth through both individual and systemic intervention. A good start is for those struggling with impostorism to have honest conversations about how these ideas shape our journeys through medicine.
Notes
Teaching tips
▸ Impostor syndrome is prevalent among health care students, residents, and experienced professionals and is a risk factor for burnout and psychological distress. Thus, it is crucial that we familiarize ourselves with its features.
▸ Anticipate impostor syndrome among learners and help by normalizing these feelings and providing reassurance that learners are not alone in their experiences.
▸ Encourage self-reflection and include impostor syndrome in wellness curricula through peer support groups or planned reflective opportunities during teaching. Formal screening with the Clance Impostor Phenomenon Scale could be considered during formal medical education evaluation.
▸ Optimize feedback to learners with immediate and specific evaluation.
Teaching Moment is a quarterly series in Canadian Family Physician, coordinated by the Section of Teachers of the College of Family Physicians of Canada. The focus is on practical topics for all teachers in family medicine, with an emphasis on evidence and best practice. Please send any ideas, requests, or submissions to Dr Viola Antao, Teaching Moment Coordinator, at viola.antao{at}utoronto.ca.
Footnotes
Competing interests
None declared
La traduction en français de cet article se trouve à www.cfp.ca dans la table des matières du numéro d’octobre 2020 à la page e270.
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