The Impostor Syndrome and Medical Education

By Anthony Llewellyn

Recently I hosted an inaugural Medical Education event in my local area.  One of the key, repeated claims from many of our speakers was of Impostor Syndrome.  It became quite a theme throughout the conference.  The typical argument went something along the line of “well really I don’t consider myself to be a medical educationalist first and foremost so I was a bit surprised to be asked to give a talk on the medical education topic of …”

Given that the participant feedback indicated a high quality of presentation and content from our speakers, the claim of Impostor Syndrome seemed to be justified.

The Impostor Syndrome was first hypothesized by a pair of  clinical psychologists Pauline Clance and Suzanne Imes in 1978 to describe a phenomenon they had observed in their practices amongst high-achieving individuals (predominantly women).  These individuals struggled to accept their accomplishments, despite contrary external evidence and constantly feared being placed in an expert role as they might be discovered to be a fraud.

By the way Impostor Syndrome is not a mental disorder, it didn’t make it into the latest DSM5.  But there are still reasons to take this issue seriously.

Is it surprising that Clinician Educators feel like imposters or is it a broad phenomenon within medicine?  In a 2008 article in the Journal of General Internal Medicine of 48 participating internal medicine residents 44% were reported in a survey to exhibit signs of “impostorisim.”  It is probably not surprising that doctors might feel fraudulent, particularly at times of transition in our medical careers. For example, when transitioning from an undergraduate to a postgraduate or when asked to talk at a medical education conference.

I’ve recently transitioned back into clinical practice and I am feeling the IS myself.  I felt that my first day in outpatient practice was possibly my worst work day in a long time.  I was particularly troubled by the amount of time it took me to document my patient encounters.  To deal with this I found it reassuring to discuss my experience and cases within a peer review group and get my documentation confidentially checked by a peer.  I soon discovered that my experience was quite normal.

One worrying consequence of IS is its potential impact on patient care. A colleague and I noticed an inverse relationship between the seniority of the trainee and the amount of times that they would review a patient with the consultant when on-call.  We had some data on the numbers of patient presentations and admission to compare  with the actual frequency of calls.  This would often get to a point of comedic-tragedic proportions where I can recall having meetings with trainees around wanting to write detailed policies about when trainees should call the consultant.  When I talked to the trainees about why it was they called more as a senior trainee versus a junior trainee their responses indicated that junior trainees felt they were not experienced enough and didn’t know enough to call the consultant (were worried about embarrassing themselves), whereas senior trainees highly valued the opportunity to discuss with a consultant because they felt it was more of a peer relationship.

I’ve talked to other colleagues from other disciplines about this observation and they have seen it as well.  By definition its not true Impostor Syndrome, but its something quite close. Doctors close in experience/capability and seniority to other doctors are less anxious about revealing a weakness than those further apart.

I am starting a simple experiment to counter this problem.  Each morning after my on-call I send the trainee a quick email thanking them for being on-call and giving them feedback on the presentations from the night before.  If I hadn’t been called I remind them that I was on-call and still hoped the night went well for them.  The results are still out.

What about you?  Have you encountered Impostor Syndrome in your work?  Have you developed any methods of addressing the seniority gap in patient handover?

Image courtesy of The Blue Diamond Gallery