Imposter Phenomenon

Many of us know the feeling – that nagging suspicion that despite all the things you have “achieved” in your lifetime, it’s really just been a combination of good timing, help from other people, a lowering of standards, people liking or taking pity on you, and/or your painstakingly maintained façade of competence.

Imposter phenomenon (IP; also called imposter syndrome) was first described in 1978 by psychologists studying a group of high-achieving women apparently incapable of internalising their achievements despite considerable success and accolades. Those suffering from IP also have remarkable capacity to internalise and ruminate upon failures, and believe that only through good luck and smooth talking have managed to create a very positive but very inaccurate impression of themselves.

Others may see the imposter as a highly capable achiever, and ask more and more of them, hoping to encourage growth and knowing they will do a great job on any task set for them. The imposter, trying desperately to maintain the façade of easy perfection, may take on more and more responsibility, downplaying the time and effort required to maintain their incredibly high standards. Alternatively, imposters may hesitate to apply for new opportunities or to evaluate themselves positively for fear that they will be exposed as failures, neither of which is helpful to career advancement or development.

Beyond merely being an unpleasant experience, these patterns increase the imposter’s risk of burnout, dissatisfaction, distress, anxiety and depression, and can lead to an intense desire to escape their responsibilities, self-sabotaging behaviours like procrastination, and withdrawal from those around them.

Of course, the self-doubt that leads to imposter syndrome isn’t all bad. Second-guessing our decisions, particularly as training clinicians, makes us safer and can provide us with increased opportunities for learning. People who never experience feelings of self-doubt exist in a much more sinister state known as sociopathy.

Imposter phenomenon is common. It’s not a permanent state, but it visits most of us from time to time throughout our careers and beyond. An awareness of when these thoughts are likely to strike can help us recognise them as just thoughts when they do.

A recent review of imposter phenomenon in academia states: “IP is more often seen in those with advanced degrees, those who have the traits of conscientiousness, achievement orientation, perfectionistic expectations, and people who work in highly competitive and stressful occupations.”

It probably won’t escape your notice that that description fits just about everyone in medicine. Many (but not all) studies suggest a preponderance for IP among women (who are often taught that modesty is a virtue), but men experience it at high rates too (despite cultural norms teaching them to suppress feelings suggestive of vulnerability). Meanwhile individuals who are in a minority group in their discipline are at higher risk regardless of whether the divide is based on race or gender (this may well stretch to other demographic divides too).

In terms of timing, we are likely to have more IP-like thoughts as we face new roles or challenges, and especially in our first jobs. If you are reading this on the eve of your internship, fear not! Although this year is probably your peak risk time for experiencing frequent imposter syndrome, you will not be alone. The vast majority of your peers will feel the same way at some point.

You’ve handled it before: the thoughts are probably familiar from your first weeks of medical school, or your first few clinical placements. They will likely return as you rotate between terms, and each time you’re called to take a step up in responsibility: supervising your first medical students, awaiting your first night shift, if you pursue a specialty and have to step up to the role of registrar, fellow, junior consultant, winding down to retirement, even outside of medicine: for example, as a parent.

The years ahead will provide you with plenty of opportunities to learn how to recognise your brain’s script for imposter syndrome, understand what is likely to trigger it for you, and figure out how you can best keep it in check at a healthy level rather than letting it dominate you.

Tips for Managing Imposter Syndrome: Connect, Reflect and Grow

Connect

Nurturing and maintaining trusting relationships with colleagues and friends is one of the best things you can do to combat imposter syndrome. You will realise that everyone feels like a fraud sometimes, even those who look as though they have breezed through their entire life feeling confident.

1. Find a “coach” and be disciplined about catching up regularly. Whether you choose a mentor, a peer, an executive coach or a therapist, it’s important that you are able to trust them and be vulnerable with them. You need to establish this habit early to maintain it when things get tough: It’s much harder to reach out for support when you already feel like a fraud.
2. Join in with any organised peer support or debriefing groups offered by your hospital (Balint groups, Schwartz rounds, RMOA peer support sessions, even some well-run M&M meetings). These are good opportunities to see that everyone in healthcare is human and we share a lot of common experiences. If there are no groups locally, you can join the “Tea & Empathy” international junior doctors’ peer support group on Faceboook (includes the option to post anonymously) or join in the conversation on #MedTwitter (in both cases, be aware of local social media policies).
3. If you are in a marginalised group, particularly within your workplace or speciality, seek out and connect with people in a similar situation. There are peer groups for women in orthopaedics, International Medical Graduates, doctors with disabilities, medical mothers and any number of other groups. If you can’t find one locally, #MedTwitter is a great place to find a supportive international community.
4. Develop opportunities for informal peer support by spending time inside or outside of work with your colleagues and other social supports.
5. Lead by example in showing empathy and courage if someone else appears to be struggling. “I feel the same way” is one of the most powerful things you can say to someone, particularly if you are their leader or their peer.

Reflect

Cultivating insight and self-compassion will serve you better in your career and life than almost any skill set.

1. Learn to recognise your imposter syndrome script. If you catch yourself thinking “I’m the only one here who doesn’t know what they’re doing” or “my patients don’t even realise they’ve drawn the short straw having me at the end of the bed” and recognise these as imposter thoughts – the congratulations, that’s half the battle! Once you get good at recognising imposter thoughts, remind yourself that they are just thoughts, not objective truths. Challenging them takes practice, but a good place to start is by taking a deep breath and examining the thoughts with a spirit of detached curiosity. You’ll find there’s lots of evidence that the thoughts are untrue.
2. Develop an awareness of high risk times for your imposter script to start playing. It’s likely to strike when you start a new job or rotation,or when you’re feeling under the pump or like you’ve been thrown in the deep end. Prepare as much as you can with the orientation resources available to you, but be aware that these are times to examine your thoughts and connect with your coach.
3. Reflective practices like journaling can help you untangle what’s going on and can help you develop technical and non-technical skills.
4. Learn about self-compassion and how to cultivate and nurture it. Imagine what a friend would say if you said your imposter thoughts out loud.
5. Play to your strengths. Research has shown that understanding your “signature strengths” of character and finding opportunities to use them increases your happiness, productivity and work satisfaction. It can also help you decide on the career path most likely to inspire you.

Grow

Cultivating a “growth mindset”– a fundamental belief that your abilities can be improved with effort and persistence – will enhance your capacity for learning and increase your ability to bounce back from adversity and failure. Many people suffering from imposter syndrome experience evaluation anxiety, but feedback, appraisal, assessments and applications are an inherent part of our training system.

1. Teach yourself to recognise the difference between good and bad feedback. This is the difference between helpful, formative, constructive feedback and feedback that doesn’t facilitate your learning, development or growth. Helpful feedback will be realistic, timely, specific (ideally with examples), direct, and focused on actions and behaviours. Feedback that is futile, vague, or personal is at best unhelpful, and at worst unprofessional.
2. Set yourself some challenging goals and reward yourself for effort rather than achievement. Decide on some personal and professional goals that are focused on skill mastery rather than performance and others’ perceptions. Make a specific plan of where, why and how, and reward yourself for sticking with the plan. This will help you to remember you are the boss of your own life (which is more than just medicine).
3. Seek opportunities to fail in a safe environment. Stretching yourself is the best way to learn, so seek out opportunities for supervision and feedback. When calling for help or advice in a clinical situation, challenge yourself to present your corridor thoughts and plan to your supervisor.
4. Learn to own your successes and embrace your failures. Try to accept appropriate compliments and useful positive feedback with a simple “thank-you” rather than attempting denial or deflection. Keep a file of achievements and positive feedback, but also pay attention to constructive criticism. Mistakes are lessons learned and a failed attempt only means you haven’t got there yet.

If you are a medical student or junior doctor, you form a part of a new generation in medicine, one that is more open than ever to showing vulnerability and emotional intelligence. This is something that should be celebrated, nurtured and encouraged.

So let me tell you now that you are enough, that you are welcome here in the big wide world of medicine, that you have strengths that contribute to your patients and your team, and that you are not supposed to know everything. You are here to learn and will continue to do so for the rest of your life.

In turn, I hope that you will pass these concepts on to those who follow you as you make your way in the world.

 Key references and resources:

• A recent review of imposter syndrome: Parkman, A. (2016). The imposter phenomenon in higher education: Incidence and impact. Journal of Higher Education Theory and Practice, 16(1), 51.
• Useful blog post on Organisational Psychology including articles on Imposter Syndrome and Growth Mindset, featuring adorable sketch-notes: https://halopsychology.com
• TED Talks: Brené Brown on vulnerability and shame and Amy Cuddy on Power Posing
• Headspace’s free ten-day crash course on mindfulness and meditation, “Take 10”
• Strengthsfinder

Dr Caitlin Weston, CF
Non-Executive Director, Doctors Health Services Pty Ltd Wellbeing Project Lead at MedApps Pty Ltd AMA (NSW) Doctors-in-Training Committee