To my friend, the impostor

It’s common to feel undeserving of your own success, to be undermined from within – but the causes and cures may lie outside you.

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I have a remarkable friend. Her name is Meredith (*it isn’t really).

For more than 20 years, she has been my counsel, both personally and professionally. We share a vocation, live locally and see each other often. I consider her one of my closest friends.

Profoundly intelligent, Meredith achieved the highest university leaving score possible, an extraordinary effort given her propensity for live music and socialising in medical school. Her journey through specialist medical training was remarkable for the glowing reviews and universal assessment success.

In the workplace, she is a clinically adept, strategic thinker who is often called on to step into leadership roles, invariably performing above expectations and steering the team safely through the storm. At any stressful juncture of my career, I have turned to her for wisdom and advice. She celebrates all of my achievements, even when I respond to my own success with disbelief and skepticism. She is an advocate, a role-model and a friend.

The only problem is that she thinks she is an utter failure.

Meredith has impostor syndrome.

The concept of the impostor syndrome was first described by Clance and Imes in 1978 when, as clinical psychologists, they encountered a large number of highly successful women who did not experience an internal feeling of success¹. At the time, they largely chalked it up as a women’s or minority group’s problem, however they have since recognised its existence in men, though research measuring the gender prevalence is mixed.

What is impostor syndrome?

Impostor syndrome can be defined as the persistent inability to believe that one’s success is deserved or has been legitimately achieved as a result of one’s own efforts or skills. It’s that feeling that your accomplishments have been derived from coincidence, connections, an amiable personality or sheer dumb luck.

Up to 70% of people have reported having impostor feelings at some time². Interest in impostor syndrome has grown exponentially in the last decade. In the medical sphere, this may be because impostor syndrome is associated with and is a predictor of depression, anxiety and burnout. These conditions contribute to physician health (or ill health) which is now clearly linked with performance and patient outcome.

It could be said that there are some positive aspects of impostor syndrome: it can spur its victims on to push themselves to maintain consistent levels of high achievement. Some say it’s a protective mechanism to keep you safe – safe from making mistakes, from over-reaching and over-committing. However, is this kind of safe the way to healthfully achieve our greatest potential?

Hutchins and Rainbolt (2016) explored the triggers and resultant feelings of impostorism in an academic facility³. These triggers and feelings easily translate to a clinical setting.

1. Having your expertise questioned (your management of a patient) leads to doubting your own expertise
2. Experiencing success (being appointed clinical director) leads to questioning your professional legitimacy
3. Comparing yourself with colleagues (peer case review) leads to distorted assessment of your own and others’ abilities
4. Scholarly productivity (how do you write a business case for more registrars?) leads to questioning your own efficacy

They concurrently noted four coping strategies employed by the academics and were interested to find that women were more likely to turn to active coping strategies such as seeking support, correcting cognitive distortion and positive self-talk, whereas men were more likely to use maladaptive coping strategies such as drinking alcohol or working to excess. This highlights the necessity to consider men to be equally at risk of experiencing impostor syndrome and monitoring for the consequences of their coping mechanisms.

Who gets impostor syndrome?

Anyone can experience it, though the literature suggests it is more prevalent in professional people. Medicine is replete with high achievers who are at risk of linking their self-worth with achievement, so it can be no surprise that impostorism is rife in within our own health care tribe.

Gottlieb et al (2019) found that gender, low self-esteem and institutional culture were associated with higher rates of impostor syndrome in physicians and trainees.

The syndrome has been traditionally attributed to personal characteristics such as perfectionism and neuroticism, but this viewpoint encourages solutions focused solely on the individual. In alignment with the burnout literature, it is becoming apparent that addressing the issue of physician health, which includes impostorism, is a shared responsibility between the individual and the organisation.

Mullangi & Jagsi (2019) said: “Impostor syndrome is but a symptom; inequity is the disease.”⁴

What do they mean?

Feenstra et al (2020) concluded that “interventions targeting the individual misses how the social context may shape one’s tendency to feel like an impostor”⁵ and that proposing individual interventions is akin to victim blaming. The authors urge us to look to the environments that elicit impostor feelings if we are ever to reverse the growing tide of perceptual failure and inadequacy.

At a societal level, the authors purport that in response to gender and leader stereotypes, women may feel insecure pursuing or attaining a leadership position, thus engendering impostor feelings.

Within the institutional context, women and minority groups are less likely to occupy certain professions and leadership roles, creating a dearth of visionary role models requiring the initiation of diversity programs.

The quality of interpersonal collegiality and communication can impact on an individual’s development of impostorism – fostering an environment where individuals are valued and experience a sense of belonging can mitigate such feelings.

There also exists a significant relationship between impostor syndrome and work-life balance; however, this is mitigated if there is good organisational support, which reinforces the role for leaders in the management of impostor syndrome and its fallout.⁶

A culture of psychological safety, fostered by inclusive leadership, where mistakes are not punished but shared for communal learning, may reduce and even prevent impostorism in its development.

How do you manage impostor syndrome?

Doctors want evidenced based recommendations, however there is a dearth of scientifically proven interventions on the topic. Time Magazine published an opinion piece on how to deal with impostor syndrome, offering suggestions including acknowledgment and sharing, but it is not the peer-reviewed literature that clinicians are calling for.

Bravata et al (2019) performed a systematic review of the prevalence, predictors, and treatment of impostor syndrome, but found the treatment literature disappointingly deficient.

Despite the evidence vacuum, some good advice from Professor Judy Robertson is to

• Understand impostor syndrome, its prevalence and unwanted consequences
• Know your triggers
• Own your success
• Stick with the facts
• Practise empathy to self and others
• Share your feelings with a trusted friend or mentor
• Lead with compassion and inclusion

Dr Caitlin Weston from Drs4drs offers the triad of Connect, Reflect and Grow to keep your impostor in check.

At the end of the day, we need organisational solutions.

We need leaders who include and recognise.

We need psychologically safe workplaces.

It’s not you, Meredith, it’s the system. It has let you down. It has let all of us down. I hold you in great esteem and if I could give you one piece of feedback to try something different, it would be to see yourself and the great contribution you make through my eyes. You are nothing short of remarkable. You are enough.

Dr Bethany Boulton is an emergency physician working on the Sunshine Coast. She is a founding member of WRaPEM (Wellness Resilience and Performance in Emergency Medicine), dedicated to bringing the non-technical skills of medicine to the fore

References

1. Clance, P., & Imes, S. (1978). The impostor phenomenon in high achieving women: Dynamics and therapeutic intervention. Psychotherapy: Theory, Research & Practice, 15(3), 241-247. doi: 10.1037/h0086006
2. Gottlieb, M., Chung, A., Battaglioli, N., Sebok?Syer, S., & Kalantari, A. (2019). Impostor syndrome among physicians and physicians in training: A scoping review. Medical Education, 54(2), 116-124. doi: 10.1111/medu.13956
3. Hutchins, H., & Rainbolt, H. (2016). What triggers impostor phenomenon among academic faculty? A critical incident study exploring antecedents, coping, and development opportunities. Human Resource Development International, 20(3), 194-214. doi: 10.1080/13678868.2016.1248205
4. Mullangi, S., & Jagsi, R. (2019). Impostor Syndrome. JAMA, 322(5), 403. doi: 10.1001/jama.2019.9788
5. Feenstra S, Begeny CT, Ryan MK, Rink FA, Stoker JI and Jordan J (2020) Contextualizing the Impostor “Syndrome”. Front. Psychol. 11:575024. doi: 10.3389/fpsyg.2020.575024
6. Bravata, D., Madhusudhan, D., Boroff, M., & Cokley, K. (2020). Commentary: Prevalence, Predictors, and Treatment of Impostor Syndrome: A Systematic Review. Journal Of Mental Health & Clinical Psychology, 4(3), 12-16. doi: 10.29245/2578-2959/2020/3.1207
7. Robertson, J., Williams, A., Jones, D., Isbel, L., Loads, D., & Maxwell, E. (2017). EqualBITE Gender Equality in Higher Education (1st ed., pp. 146-151). BRILL.
8. Weston, C. (2021). Impostor Phenomenon. Retrieved 18 August 2021, from https://www.amansw.com.au/impostor-phenomenon/