How Feeling Like an Imposter Can Impede Your Success.

Medicine is often characterized as a “high-stakes” profession, with an evaluative culture, little room for error, and a tendency to be populated by high achievers (1). From the outset, physicians are trained in a culture that expects excellence and the provision of superb patient care with little room for failure. As a result, when an error or expectation is not met, this can create inaccurate self-assessments streamed with anxiety, guilt, and self-doubt (1). Male and female physicians at all career levels have reported self-questioning and feelings of inadequacy, which tie into the imposter phenomena (1).

Imposter syndrome (IS) is the phenomenon of feeling inadequate or fraudulent despite having the qualifications, accolades, and attributes to succeed. This was first described by Drs. Clance and Imes (2) as a perception of professional and intellectual fraudulence. The individual has a fear of being exposed as an imposter and usually has difficulty accepting compliments on their successes (Figure 1) (3).

Figure 1

Coping With Imposter Syndrome

Masks–stock vector. www.gettyimages.com. Dane_mark #613769026. Getty Images, 2020.

Despite appearing in peer-reviewed and lay literature, talks, podcasts, and presentations, IS has not yet been recognized as a psychiatric disorder and is not listed as a diagnosis in the International Classification of Diseases-10th Revision (4). A recent systematic review reports a widely varied prevalence of 9% to 82%, but there are no consistent data on its true frequency (4). Multiple scales have been created to examine an individual’s own perception of IS such as the Clance Impostor Phenomenon Scale, Harvey Imposter Phenomenon Scale, Perceived Fraudulence Scale, and Leary Impostor Scale; however, none of these are validated (3).

Given the excessively demanding nature of the medical profession, especially in competitive subspecialties such as cardiology, it is only natural that the vast majority harbor at least some characteristics of IS in environments that perpetuate such behavior. This, coupled with the fact that physicians are prone to measuring their self-worth through clinical, academic, or professional achievements (5), provides the perfect petri dish for growth of IS. As such, there should be acknowledgment, discussion, and solutions provided so that physicians can utilize tools to combat this phenomenon.

Given the scarce published literature on IS and drawing from personal experiences, one can speculate that potential personality traits might predispose to IS. Excessively goal-oriented perfectionism (1) and tendency toward being a “people pleaser” may result in failing to ask task-relevant questions for fear of being “found out” as a fraud. This in turn leads to further anxiety and distress arising from any repercussions of failure (1). Although first described in high-achieving women (2), IS also affects men (4). However, unlike issues such as workplace discrimination, which are more externally manifest and can be counteracted with tangible measures, those suffering from IS may lack self-awareness or tend to initially internalize these feelings, leading to self-criticism and a reluctance to open discourse (1,5).

IS may manifest as early as medical school or postgraduate training. Matching at a leading academic institution could lead to IS, with a tendency to attribute the accomplishment to good luck, timing, or a recommendation instead of one’s own merit, potentially leading to a sense of “not belonging” or not deserving to be in the current job. Paradoxically, even the positive effects of mentorship and sponsorship are at risk of being detrimental, with some even perpetually attributing their success to opportunities afforded by mentors instead of their own efforts. Thoughts such as “I achieved this because it was handed to me” are accompanied by a constant feeling of anxiety and not being able to live up to expectations.

Upon completion of training and transition to independent practice, this phenomenon might lead to a continued lack of confidence, feelings of inadequacy, and fear of making mistakes (“I cannot handle this case alone as well as my attendings did”). Particularly in early and midcareer stages, self-perception of being underqualified could potentially lead to significant career setbacks and missed opportunities, particularly when applying for academic promotions and tenure. Even in late career, there may be a tendency toward self-doubt, doubting achievements and suitability for various opportunities, causing further missed opportunities for leadership of and within local, national, and international professional organizations and committees that would benefit from lifelong experience, contributions, and expertise.

IS can have an immense impact on mental health and wellness. Although it may be a fluctuating phenomenon in some, IS may be continuous in many individuals, and can perpetuate a vicious cycle of negative self-attribution, lack of self-confidence, and even self-sabotage. The inability to celebrate genuine successes and the constant pursuit of excuses to justify achievements may have debilitating effects on self-confidence and self-esteem, fueling symptoms of anxiety, and potentially even depression (4). This detrimental impact is further perpetuated by a demanding workplace environment and may contribute to physician burnout (4).

Powered by a need for perfectionism, an overlying sense of self-doubt and need to prevent discovery of a fraud, “imposters” might set themselves challenging and sometimes unattainable goals. This can eventually lead to an inability to cope with the disappointment of failure and perpetuate a vicious cycle of frustration, burnout (4), and negative thoughts. In a constantly demanding profession, such negative self-talk halts career progression and development and can also have detrimental effects on the entire health care profession, hospital systems, and in turn, patient care. Thus, it is imperative to openly converse about, rectify issues that surround, and develop healthy tools and habits for counteracting these antagonistic feelings once they arise.

IS often coexists with depression, anxiety, low self-esteem, somatic symptoms, and social dysfunction (4). Critically, there have been no trials of therapeutic interventions to treat individuals with IS. Strong consideration should be given to screening individuals with IS for depression and anxiety and offering evidence-based therapies for these conditions. Additionally, because individuals experiencing IS often perceive themselves to be the “only one” having these feelings, resulting in even greater isolation, referral to group therapy in which peers and coworkers discuss their feelings of doubt and failure might be particularly therapeutic. Clinicians and other high-achieving professionals may be reluctant to participate in such groups unless they are carefully designed to normalize and destigmatize imposter feelings and provide a safe environment in which to share experiences openly.

Self-reflection and reframing are also important ways to recognize and overcome IS. Seeking specific, honest, and accurate feedback from trusted individuals may help those with IS to better self-reflect and recognize positive attributes and acknowledge hard work, whereas more generalized feedback lacking personalization may be more easily discounted.

Reframing losses as lessons, focusing on what can be learned from a perceived negative experience, and identifying what could have been done differently to change an outcome can also help on the path toward more constructive, rather than negative, thinking. Lastly, aligning actions and decision-making with core values or an “internal compass” that helps to give a “big picture” or “long range” view of a situation may also help some to better reduce feelings of insecurity from IS.

IS is more ubiquitous than many realize. At some level, it is very likely that most have either encountered or continue to face IS. It is important to remember that health care providers are not only professionals, but also humans, with human fears and vulnerabilities. Shedding light on these vulnerabilities will offer a path toward personal growth and will be the key to overcoming IS. Perhaps Nelson Mandela said it best: “I learned that courage was not the absence of fear, but the triumph over it. The brave man is not he who does not feel afraid, but he who conquers that fear” (6).

Funding Support and Author Disclosures

The authors have reported that they have no relationships relevant to the contents of this paper to disclose.