Imposter phenomenon is a frequent experience among U.S. physicians, and disappointment in present accomplishments is more common in physicians than in other professions, according to the results of a national survey.
“Imposter phenomenon” (IP) describes the experience of a high-achieving person who feels as though their success was undeserved and who maintains feelings of self-doubt despite evidence of ability and achievement. Researchers surveyed physicians across the United States to understand the prevalence and consequences of IP, and the results of the study were published in an issue of Mayo Clinic Proceedings (2022;97[11]:1981-1993).
“Although physicians are compassionate with others, they often hold themselves to unrealistic expectations and are perfectionistic and self-critical,” said lead study author Tait Shanafelt, MD, the Jeanie and Stewart Ritchie Professor of Medicine and associate dean at the Stanford School of Medicine, in California. “Studies in medical students and residents had also suggested that many physicians compare themselves to their peers and have a sense of inadequacy. We wanted to explore these dimensions more deeply in a group of practicing physicians in the United States who had completed their training.”
A total of 3,116 physicians completed the questionnaire, which measured IP via a four-item version of the Clance IP Scale. For each of the measures, between 4% and 10% of survey respondents said the characterization was “very true” for them. Overall, 40.4%, 36.4%, 17.4% and 5.8% of respondents had IP scores in the minimal, moderate, frequent and intense IP ranges, respectively.
This finding did not come as a surprise to Dr. Shanafelt, who explained why feelings of self-doubt could be so prevalent among high achievers.
“Physicians are a motivated and highly talented group of individuals. They are high achievers and, prior to their medical training, typically performed at the top of their class. Once they enter medical student training, they are often in an equally talented peer group for the first time. A number of professional norms and aspects of the culture of medicine also suggest that physicians should be impervious to normal human limitations,” Dr Shanafelt said. He explained that this combination of professional norms and a highly accomplished peer group can lead to feelings of inadequacy for many physicians that also contributes to IP.
“There is a fine line between being a perfectionist and allowing that attention to detail to get in your way,” said Kaci Schiavone, MD, a general surgery resident at the University of Rochester Medical Center, in New York, who was not involved in the study. “Medicine, and the field of surgery in particular, emphasizes answering the question: ‘What could we do better next time?’ And, in some ways, that creates a focus on the negatives, or the past failures. If we dwell on those instead of putting equal emphasis on the successes we’ve had, we create an environment that is ripe for feeling like you are not good enough or that you do not belong.”
The study also found that burnout, professional fulfillment and suicidal ideation were linked to IP score. Compared with physicians who had low scores, the odds ratios for burnout among those with moderate, frequent and intense IP scores were 1.28 (95% CI, 1.04-1.58), 1.79 (95% CI, 1.38-2.32) and 2.13 (95% CI, 1.43-3.19), respectively.
“Imposter phenomena had a large and significant association with occupational distress in this national study of U.S. physicians. Extensive evidence has shown burnout among physicians impacts quality of care, cost of care, patient experience and access,” Dr. Shanafelt said.
Linda Wong, MD, a liver transplant and hepatobiliary surgeon at the University of Hawaii Medical Center, in Honolulu, who was not involved in the study, explained how pressures of the work environment might contribute to disillusionment and lack of fulfillment for physicians. “We went into medicine to save lives, to make a difference—and all of the physicians are entrenched in paperwork, administrative duties, lots of meetings and emails, and so many rules.”
In multivariable analysis, in response to the phrase, “I am disappointed at times in my present accomplishments and think I should have accomplished more,” physicians reported greater intensity of IP than workers in other fields.
“When you work really hard for a high-level job, you have these great expectations that your life is going to be perfect once you finish medical school and residency, and you get a job,” Dr. Wong noted. “You have all these expectations built up, and it doesn’t quite meet that. I think that the average worker may not have these kinds of expectations.”
After adjusting for factors including age, sex, relationship status, hours worked per week and other variables, disappointment in present accomplishments remained associated with burnout and professional fulfillment, and physicians maintained greater IP intensity than workers in other fields.
“I don’t think imposter syndrome is one-size-fits-all,” Dr. Schiavone said. “It can affect any member of this community in a multitude of ways at any time in their careers, and just being cognizant of how we talk about ourselves and each other can have a lasting impression on the next generation ... Diversity in medicine and surgery is a key component of minimizing feeling like a fraud—if you can’t see yourself in the people around you, then you are at higher risk of having feelings of not belonging.”
There is a need for system-level efforts to address the professional norms and perfectionistic attitudes that contribute to IP, Dr. Shanafelt said. One useful approach is having senior faculty members share their “failure resumé,” which can help younger faculty realize that they are not alone in their struggles and that senior faculty who seem to have everything together went through similar challenges early in their career.
“It also creates vulnerability and authenticity that allows physicians to share their challenges with one another,” Dr. Shanafelt said. He suggested that storytelling events, small groups meeting regularly to discuss the virtues and challenges of a career in medicine, and efforts to replace a mindset of perfectionism with commitment to excellence and growth can be helpful, too.
“Be open to discussing your personal experience with imposter syndrome, as it can help others who are truly struggling,” Dr. Schiavone said. “Regardless of career stage, there are people around us who look up to us who may internalize comments we make about ourselves and others, which can lead to feelings of not being good enough.”
“Although we often do heroic things, we are humans and are subject to normal human limitations,” Dr. Shanafelt said. “We need to cultivate a professional environment of vulnerability that allows colleagues to better support each other.”
—Jenna Bassett, PhD
This article is from the November 2023 print issue.