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The Imposter Syndrome in Physicians

  • Thomas J. Beckman
    Correspondence
    Correspondence: Address to Thomas J. Beckman, MD, Department of Medicine, Mayo Clinic, 200 First St SW, Rochester, MN 55905
    Affiliations
    Professor of Medicine and Medical Education, Mayo Clinic College of Medicine and Science, Department of Medicine, Mayo Clinic, Rochester, MN
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      Imposter syndrome (IS), also known as imposter phenomenon or imposterism, is defined as feelings of uncertainty, inadequacy, and being undeserving of one’s achievements despite evidence to the contrary. Imposter syndrome has 5 subtypes
      • Young V.
      The Secret Thoughts of Successful Women: Why Capable People Suffer from the Impostor Syndrome and How to Thrive in Spite of It.
      :
      • Perfectionist: insecurity related to self-imposed, unachievable goals
      • Expert: feeling inadequate from lacking sufficient knowledge
      • Super-person: assuming excessive workloads just to feel okay among peers
      • Natural genius: experiencing shame when it takes effort to develop a skill
      • Soloist: believing that requesting help is a sign of weakness
      Imposter syndrome is not a formal psychiatric diagnosis. It occurs among extraordinarily accomplished people. For example, Chief Justice Sonia Sotomayor acknowledged spending years “always looking over my shoulder, wondering if I measure up.”
      Imposter syndrome was first studied among women,
      • Clance P.R.
      • Imes S.A.
      The imposter syndrome in high achieving women: dynamics and therapeutic intervention.
      although it is now recognized to be widespread. It is common among physicians,
      • Shanafelt T.D.
      • Dyrbye L.N.
      • Sinsky C.
      • et al.
      Imposter phenomenon in US physicians relative to the US working population.
      who are at risk for several reasons. First, they may overvalue a profession they worked so hard to enter; in the words of Groucho Marx, “I refuse to join a club that would have me as a member.” Second, it is impossible to remain entirely abreast of the unlimited, constantly evolving knowledge of Medicine. Third, physicians are surrounded by intelligent and successful colleagues, which perpetuates endless comparisons and competition. Fourth, there is the problem of heroism among physicians.
      • Wheeler H.B.
      Shattuck lecture. Healing and heroism.
      On balance, it is evident why doctors would worry about measuring up to the occupation's standards and one day being discovered as the mortal beings that they are. Supporting this, research has shown that IS tends to occur in people who are high achieving and perfectionistic.
      • Bravata D.M.
      • Watts S.A.
      • Keefer A.L.
      • et al.
      Prevalence, predictors, and treatment of imposter syndrome: a systematic review.
      ,
      • Henning K.
      • Ey S.
      • Shaw D.
      Perfectionism, the imposter phenomenon and psychological adjustment in medical, dental, nursing and pharmacy students.
      In this issue of Mayo Clinic Proceedings, Shanafelt et al,
      • Shanafelt T.D.
      • Dyrbye L.N.
      • Sinsky C.
      • et al.
      Imposter phenomenon in US physicians relative to the US working population.
      who are acclaimed for research on physician well-being and distress, describe IS among 3237 US physicians. Their use of a national database generated perhaps the largest study on this topic and a unique ability to investigate associations with burnout and to compare rates of IS for physicians vs other professionals. They incorporated the standardized Clance Imposter Phenomenon Scale, although they used only 4 of the original 20 scale items. They discovered that among physicians, IS occurs commonly and more frequently than with workers in other fields. Finally, they identified higher rates of IS in physicians who are women, younger, and employed at the Veterans Health Administration or academic settings.
      In addition, they saw an association between IS and suicidal ideation and suggested that this may indicate unmeasured depression among the study participants. However, we should also realize that for some of the participants, IS might have been a direct measure of depression, as reinforced by the known overlap between IS, depression, and anxiety.
      • Bravata D.M.
      • Watts S.A.
      • Keefer A.L.
      • et al.
      Prevalence, predictors, and treatment of imposter syndrome: a systematic review.
      Imposter syndrome could be acceptable in smaller doses. A useful framework for this concept is Millon’s personality styles, which proposes that personalities lie along a spectrum,
      • Strack S.
      Millon's normal personality styles and dimensions.
      such that people with normal personalities adapt to their environments, whereas those with pathologic personalities are more rigid. Arguably, people with modest amounts of IS could be viewed as unpretentious. Indeed, research indicates that humility is associated with strength and sound psychological adjustment, whereas lack of humility is linked with narcissism and entitlement.
      • Exline J.J.
      • Geyer A.L.
      Perceptions of humility: a preliminary study.
      What is the opposite of IS? Recall that IS occurs in successful people who feel inadequate despite evidence of their achievements. Contrarily, the Dunning-Kruger effect describes people who overestimate their abilities in areas where they have low performance.
      • Dunning D.
      The Dunning-Kruger effect: on being ignorant of one's own ignorance.
      It is the classic example of not knowing what you don’t know. For instance, in the field of psychology, it was reported that people with low health literacy had more confidence in health knowledge than those with higher health literacy.

      Canady BE, Larzo M. Overconfidence in managing health concerns: the Dunning-Kruger effect and health literacy. J Clin Psychol Med Settings. Published online June 29, 2022. https://doi:10.1007/s10880-022-09895-4

      Within medical education, researchers demonstrated that high performers significantly underestimated—and low performers significantly overestimated—their knowledge performance on a standardized examination.
      • Mehdizadeh L.
      • Sturrock A.
      • Myers G.
      • Khatib Y.
      • Dacre J.
      How well do doctors think they perform on the General Medical Council's tests of competence pilot examinations? A cross-sectional study.
      Experts have suggested the following treatments
      • Palmer C.
      How to overcome impostor phenomenon.
      for IS: (1) Review and celebrate feats that have led to your professional role. (2) Share concerns with trusted colleagues who can validate your accomplishments and normalize your feelings by reporting their own struggles with IS. (3) Combat perfectionism by accepting that it is okay to be good enough when meeting the challenges of a demanding profession. (4) Exercise self-compassion as an alternative to relying on an external locus of self-worth. (5) Understand that IS may be common, especially during transitions such as entering medical school, graduate medical training, or a new career.
      Finally, IS could be treated by deemphasizing our professional identities and taking comfort in knowing that our real impact is based not on titles and recognition but on how we cultivate kindness and enhance other people’s lives, even in simple ways that are unrelated to our formal roles. Supporting this concept, scholars have discerned that people may forget what we said or did, but they will never forget how we made them feel.
      • O'Toole G.
      They may forget what you said, but they will never forget how you made them feel. Quote Investigator website.

      Potential Competing Interests

      The author reports no competing interests.

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      1. Canady BE, Larzo M. Overconfidence in managing health concerns: the Dunning-Kruger effect and health literacy. J Clin Psychol Med Settings. Published online June 29, 2022. https://doi:10.1007/s10880-022-09895-4

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        How well do doctors think they perform on the General Medical Council's tests of competence pilot examinations? A cross-sectional study.
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