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 (IS). It became quite a theme through 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 most justified.
The Impostor Syndrome was first hypothesized by a pair of female 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) who 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.
Is it surprising that medical educationalists feel like imposters or is it a broader phenomenon in medicine itself? Well, in a 2008 article in the Journal of General Internal Medicine, of the 48 participating Internal Medicine residents 44% were found on the survey to exhibit signs of “impostorisim”. It’s probably not surprising that, particularly at times of transition in our medical careers, we as doctors might feel a bit more fraudulent, for example when transitioning from an undergraduate to a postgraduate as the JGIM article shows or when someone gets asked to talk at a medical education conference for the first time not many of us appear to deliberately set out to become medical educators.
I’ve recently been undergoing a transition back into some clinical practice and feeling the IS myself a bit. I felt that my first day in outpatient practice was possibly my worst workday 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 some of my documentation confidentially checked by a peer. I soon discovered that my experience was quite normal.
By the way, Impostor Syndrome is not a mental disorder it didn’t make it into the latest DSM5. But there are still reasons, in my opinion, to take this issue on seriously.
One worrying possible consequence of Impostor Syndrome is its potential impact on patient care. I observed this issue at play some time ago in my psychiatry training program. A colleague and I noticed a pattern in the psychiatry trainees and their behavior when on-call after hours. We noticed that there was an inverse relationship between the seniority of the trainees and the number of times that they would call the Consultant to review a patient.
We had some reasonable data on the numbers of patients presenting and were aware of how many patients were being admitted overnight and so we could compare this 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. I pointed out at the time that this didn’t seem to be the real problem as the Consultants were always happy to be called and if we wrote a policy and a trainee didn’t follow it (which I assessed was a high probability) this would create even more problems for the trainee.
When I talked to the trainees about why it was they called more as a senior trainee versus a junior trainee the 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 and they even confessed that perhaps they were calling a little more than they felt they really needed to because they had already made a good assessment and plan ”bounce things off the Consultant”.
I’ve talked to other colleagues from other disciplines about this observation and they have observed it as well. By definition, its not true Impostor Syndrome but it’s something quite close; doctors close in experience and/or capability and/or seniority to other doctors are less anxious about revealing a weakness than those further apart.
I haven’t been an on-call Consultant for a little while but when I was I tried a simple experiment in countering this problem. Each morning after my on-call I would send the trainee doctor a quick email thanking them for being on-call and giving them some feedback on the presentations from the night before. If I hadn’t been called at all I would remind them that I was on-call and still hoped the night went well for them. My experiment didn’t last long enough for me to know whether it had an effect on the Trainee Impostor Syndrome but as I am shortly returning to on-call again I think I might give it another go.
What about you? Have you encountered Impostor Syndrome in your work? Have you developed any methods of addressing the seniority gap in patient handover?
Footnote: We were very fortunate indeed to have Jason Frank as our international speaker for our Conference. There were many points as to why we decided to hold a local #MedEd event but the primary reason was that we wanted an event where we could bring all the key players in the medical training pipeline together in one room for two days. On that measure our event was a great success as it spawned a lot of collaborative conversations from organizations that attended including after the event. It’s often stated that the real learning at a Conference happens at the sidelines.
