Tackling imposter syndrome

By Andrea Niermeier, Contributing Writer, September 1, 2023

You have made the grade, completed the training, and committed your professional life to helping individuals become and stay well. So why do you sometimes feel like you don’t belong in a room of accomplished colleagues, question whether you’ve truly earned an accomplishment, or feel paralyzed by the fear of making a wrong diagnosis? The answer may be a way of thinking often referred to as imposter syndrome (IS), which is characterized by persistent feelings of inadequacy or self-doubt despite objective proof of competence and achievement.

While Pauline Rose Clance and Suzanne Imes first used “imposter phenomenon” to describe the psychological construct in 1978, many refer to it as “imposter syndrome” today. A certified life coach, Sara Dill, MD, FAAD, explained why this wording may be too pathological. “‘Syndrome’ makes it seem like something is wrong with the person, something pervasive — even permanent — which is not the case.” While she currently practices medicine and coaches physicians on burnout, stress reduction, and wellness, Dr. Dill took a sabbatical from practicing dermatology in 2012 due to her own burnout, partly from imposter phenomenon. Understanding imposter syndrome as a common way of thinking that can be overcome is important to maintaining a healthy personal and professional life.

Tait Shanafelt, MD, hematologist, Jeanie and Stew Ritchie Professor, and chief wellness officer at Stanford Medicine, described how these imposter feelings begin to fester. “Although physicians are compassionate with others, they often hold themselves to unrealistic expectations and are perfectionistic and self-critical.” A physician experiencing IS may downplay achievements, overprepare or overachieve, self-sabotage, or pass up on opportunities because they don’t feel qualified. “I’ve certainly coached clients who have been asked to speak or publish more but who are doubting their abilities,” Dr. Dill recalled. “They may actually turn down these offers or accept them with a great deal of stress. IS can limit success — in these instances, you truly work against yourself.”

Studies show that this phenomenon does not begin once a person becomes a doctor. IS is common among medical students and residents who feel inadequate as they compare themselves to their peers. In a study of dermatology residents in 2019, 89% of the 121 people surveyed had IS with moderate-to-intense imposter tendencies, with 92% of females and 85% of males reporting symptoms. Dr. Dill noted that while imposter syndrome has often been thought to disproportionately affect women more than men, studies have shown that IS is reported at a higher percentage in many minority groups, potentially suggesting that a lack of equal representation in a field can influence imposter feelings. Even so, IS affects a high portion of the general population; in the aforementioned JAAD study, 56% of dermatology residents reported burnout in at least one of the medical personnel scale categories.

Medical training may also contribute to IS. Dr. Dill explained that often during training, a student is pushed to examine where they may be wrong or what they don’t know, leading to feelings of self-doubt. Furthermore, the limited number of residency positions create competition among students, causing feelings of anxiety and inadequacy.

“One of my favorite professors said that being in the medical field and going through training involves getting comfortable with being uncomfortable. When we are put in uncomfortable situations, we will likely experience self-doubt.”

Imposter tendencies can begin early in a medical student’s education — when students are in high-achieving and motivated peer groups learning a vast amount of information. “Once they enter medical student training, they are often in an equally talented peer group for the first time,” Dr. Shanafelt acknowledged. This can lead to feelings of deficiency since they are accustomed to being the top performer. According to a pilot study in 2014 that investigated IS and burnout among American medical students, almost a quarter of male medical students and nearly half of female students experienced IS, significantly contributing to burnout.

William James, MD, FAAD, emphasized that students’ understanding of these feelings as part of the natural process of learning — and not as a reflection of their abilities — is important. Paige Porter, MS, a third-year medical student at Mercer University, echoed this sentiment. “One of my favorite professors said that being in the medical field and going through training involves getting comfortable with being uncomfortable. When we are put in uncomfortable situations, we will likely experience self-doubt.” Porter explained that she has felt insecure at times in her medical training despite her well-earned achievements. However, learning more about IS has helped her continue past her doubts.

While IS has been observed in many professions, a Stanford-led study published in Mayo Clinic Proceedings, authored by Dr. Shanafelt and colleagues, showed imposter phenomenon experiences to be more common among U.S. physicians than people in other occupations. In addition, physicians had more frequent experiences of disappointment in accomplishments. Dr. Shanafelt highlighted, “Most people project that physicians are highly educated and accomplished professionals who are engaged in important work, are well respected by society, and experience a high sense of professional achievement. The notion that many experience disappointment in their accomplishments and believe they are due to chance rather than hard work and talent may be somewhat surprising to those outside the field.” Dr. Shanafelt also noted that these numbers persisted even after adjusting for age, gender, relationship status, hours worked per week, and other factors. “A number of professional norms and aspects of the culture of medicine suggest that physicians should be impervious to normal human limitations. The combination of professional norms and a highly accomplished peer group can lead to feelings of inadequacy and contribute to imposter phenomenon,” he added.

The prevalence of IS in high-achieving and highly educated people in a competitive field partly explains the high percentage of affected medical professionals. However, the demands of the job also play a role. Dr. Dill observed, “In medicine in particular, we are trained to look for the problem and to run the differential diagnosis on a patient. While this can be a useful exercise, when we turn that onto ourselves — looking for what’s wrong or finding a different explanation — it can be problematic.” She elaborated that those in medicine want to help people, and the pressure of making an error can weigh heavy on a practitioner who is facing an ill patient or the worry of litigation or malpractice.

This mindset of perfectionism is ultimately burdensome for the physician.

In addition, technology may contribute to IS. Dr. James recounted, “Early in my career, I might go a year or two without any substantial new medicine. It is an exciting time to be a doctor; but it is also one in which you feel like you need to learn new things at a faster pace. I think that causes even the most experienced physicians to feel like they must catch up, leading to insecurities.” Dr. Dill also highlighted the impact of technology on a physician’s self-esteem with the availability of online reviews. “People tend to post more negative than positive experiences, and these reviews are easily accessible.” Negativity bias can cause physicians to feel like an imposter or fraud in their field.

Strategies for mitigating IS

Dr. Dill believes that one of the first ways to address IS is to identify the thoughts feeding it. The Clance Imposter Phenomenon Scale, created in 1985 and validated in 1995, is a 20-item questionnaire that helps individuals determine whether they have IS characteristics and, if so, to what extent they are suffering. The higher the score, the more frequently and seriously imposter syndrome interferes in a person’s life. View the scale.

This can be an important tool for physicians and medical students. However, while IS is very common, Drs. Dill and Shanafelt both pointed out that doctors may not readily share their imposter tendencies with peers due to the misconception that everyone else is not experiencing the same feelings. In fact, Porter and Dr. James co-wrote a journal article about IS in medical training from a need they saw to emphasize the commonality of these feelings in medicine. According to Dr. Shanafelt, hiding rather than discussing these feelings with colleagues can decrease authenticity and prevent colleagues from supporting one another through the emotional highs and lows of the work. In these cases, physicians may isolate, reinforcing a lack of vulnerability with colleagues.

Critically, IS should not be ignored by the medical community. Dr. Shanafelt reported, “Imposter phenomena had a large and significant association with burnout and occupational distress in our national study of U.S. physicians. Extensive evidence has shown burnout among physicians to impact quality of care, cost of care, patient experience, and access.” In the study, high IS scores strongly correlated with the emotional exhaustion and depersonalization domains of burnout.

Elaborating on some of these key components of burnout, Dr. Dill explained that second guessing oneself or rehashing a patient encounter can contribute to a loss of efficacy and meaning. “It just gets exhausting and takes away a lot of the fun, joy, and meaning that you can have in practicing medicine in dermatology.” This may deter people from seeking new or challenging opportunities. She also pointed out that a doctor experiencing imposter syndrome may feel more defensive, creating more difficult patient-doctor relationships and further causing low professional fulfillment.

While burnout is a concern related to IS, other serious psychiatric comorbidities, such as depression and suicide ideation, are also associated with frequent and intense IS experiences. Dr. Shanafelt stated, “All physicians make tremendous sacrifices for their patients. If they feel inadequate about their work accomplishments, they may be less likely to set healthy limits and sacrifice personal needs for professional needs to an unhealthy degree, increasing emotional exhaustion.” This may include excessive work hours, poor work-life integration, deferral of self-care, and harsh responses to perceived shortcomings. Seeking early and professional intervention is essential in these cases.

With IS affecting a large portion of medical students, residents, and physicians, addressing this phenomenon may take both systemic and individual efforts. Dr. Shanafelt stated, “System-level efforts to address the professional norms and perfectionistic attitudes that contribute to imposter phenomenon are needed.” This may include having a senior member of the group share their “failure resume” summarizing challenges they went through in their career at each monthly department meeting. Not only does this demystify junior physicians’ inaccurate perception that senior colleagues do not struggle in their career, but it also creates vulnerability and authenticity that allows physicians to share their challenges with one another. Other potential approaches include storytelling events or Colleagues Meeting to Promote and Sustain Satisfaction (COMPASS) groups.

“Imposter phenomena had a large and significant association with burnout and occupational distress in our national study of U.S. physicians. Extensive evidence has shown burnout among physicians to impact quality of care, cost of care, patient experience, and access.”

In addition, Dr. Shanafelt suggested system interventions that evolve professional culture — including affirming the importance of self-valuation, reducing perfectionism, and fostering a growth mindset. He noted, “Although we often do heroic things, we are humans and are subject to normal human limitations. We need to cultivate a professional environment that allows colleagues to better support each other.” These systemic paradigm shifts must also include medical school and residency training processes.

To address IS as an individual, Drs. Shanafelt, Dill, and James all agree that an important first step is recognizing that these feelings are common. Dr. Dill acknowledged, “There’s relief knowing that it is normal and does not reflect your abilities. While there is utility in asking yourself if you need to learn something, the pervasive sense of not being good enough — that’s the lie to look at.” Dr. Dill recommends identifying unhelpful thought patterns by writing down specific negative thoughts, choosing one target thought, and creating a new goal thought to eventually replace the negative feeling. Recognizing efforts and accomplishments that support the goal thought as well as using thought bridges can help a person replace the untrue, unhealthy feeling with a more accurate and beneficial one. Dr. Shanafelt also addressed the importance of identifying accomplishments adding, “No individual graduates from medical school or completes residency and fellowship training due to chance or luck. Accomplishing these things requires talent, aptitude, and hard work.” In addition, learning how to receive and accept praise for these accomplishments may be important work for overcoming harmful thought patterns.

Dr. James and Porter emphasized the importance of having a growth mindset to counteract feelings of IS. “I think that a physician or student has to come to the realization that they are probably never going to feel fully prepared for a situation. If you are going to grow by doing something different than you’ve done before, there’s always going to be some doubt,” Dr. James suggested. Porter agrees. “Having a holistic view and not getting bogged down with negative thoughts is important. I don’t believe I’ll ever feel 100% comfortable, but I believe I’m doing everything that I need to be doing, and I can learn what I need to learn.” Responding to a high-anxiety situation with the confidence to figure it out rather than insecurity helps deter imposter thinking. In addition, reframing perceived failures as opportunities for learning and growth helps a person manage disappointment without allowing it to define them.

Besides working to change unhealthy thought patterns, creating professional mentor relationships, sharing with others, and asking for help are important strategies for managing IS. Dr. Shanafelt warned against comparing yourself to colleagues in every domain of personal and professional life, and instead recommended finding a group of trusted colleagues with whom you can be authentic. “Meeting with them at regular intervals to discuss the ups and downs of your careers can be a helpful approach to affirm our common humanity, foster self-valuation, and mitigate imposter syndrome.” In addition, he suggested working with an executive coach can be a helpful approach to prioritize personal needs and respond to imperfection with a growth mindset instead of self-criticism.

As a coach, Dr. Dill wants people to understand that experiencing IS does not mean a person is condemned to a life-long feeling of not being good enough. She believes that although it might be a tendency, it is one that people can move beyond to achieve both personal and professional satisfaction. Through tools such as awareness, mindfulness, coaching, and community, she has found her way back to a thriving dermatology practice — one that she enjoys. “There are different ways to change the perceptual lens through which you see yourself and the world,” she suggested. This lens may be the key to a long, healthy, and rewarding career in medicine.

Additional DermWorld Resources