I will never forget the first medication I ordered as newly practicing physician. It was my first internal medicine rotation of residency. I was terrified to place the order, so sure I was going to harm the patient. The medication was Tylenol.
The transition periods of medical training are so uncomfortable. One day you are a medical student, and the day after graduation, a resident physician. Then you are a resident, and the day after that graduation, a full-fledged physician. There is nothing magical that happens during these transitions, no opening of the clouds with light coming down from the heavens to bestow a new sense of mastery over everything you learned in the last eight years. And there’s certainly no magical bump in your confidence, or at least, there wasn’t for me. I was scared to order Tylenol.
I remember feeling so unsteady as a fresh third-year medical student, during the arduous and intense twelve weeks of internal medicine training, which was full of regular long days interspersed with every three or four day 30-hour shifts. The immensity of complicated patient care at that point in my education eroded any previous sense of confidence, as these were no longer practice patients with pretend diagnoses. They were the real deal. I felt so overwhelmed. I really believed I wasn’t a good medical student, that I wasn’t going to make it as a physician, that I wasn’t as capable as the other members of my team.
Part of the midway evaluation during this rotation was to meet with the senior resident to not only get feedback, but to first let the resident know how I thought I was doing on the rotation. Of course, I thought that I wasn’t doing well, comparing myself to the other students, residents, and physicians I worked with, others whom always seemed to know more, remember more, and be more sure in their medical decision making.
She surprised me by telling me that I was doing very well, better than expected actually, for where I was in my training. She remarked that I was comparing myself to fourth year medical students, to interns, to second year residents, and so of course I did not feel like I was measuring up. She urged me to just trust the process of learning to become a physician. I was right where I needed to be and would continue to learn and grow into my competence.
I was experiencing imposter syndrome, which still creeps into my self-critical thoughts from time to time, though the voice is getting softer the longer I practice medicine. Imposter syndrome can be defined as “an internal experience of believing that you are not as competent as others perceive you to be” as well as a psychological condition in which “an individual doubts their skills, talents, or accomplishments and has a persistent internalized fear of being exposed as a fraud.” Imposter syndrome often co-exists with perfectionism, low self-esteem, as well as anxiety and depression. Working in medicine is not the only place that imposter syndrome shows up; it is commonly experienced in individuals of all professions, ethnicities, as well as all genders. In fact, Up to 70% of people will feel like an imposter at least one time during their lifetime.
Imposter syndrome was first discussed in an article published in 1978, “The Impostor Phenomenon in High Achieving Women: Dynamics and Therapeutic Intervention" by Pauline R. Clance and Suzanne A. Imes. Later in 1985, a scale was developed (Clance Imposter Phenomenon Scale), which included something the authors called the “imposter cycle,” a desire to be the best or like a superhero, the inability to accept praise, a fear of failing, as well as feeling guilty about any success achieved. The scale would indicate if someone had imposter syndrome when at least two of these elements were present.
So, if many of us will experience imposter syndrome at some point in our lives, what does one do about it? The place to start is to first internally recognize the feeling of imposterism, just as I did during my transitions from student to resident, and then from resident to attending physician. The second is to say it out loud, “I feel like an imposter,” preferably to others who do similar professional work. The mirroring that occurs, the “me too!” feedback, takes such a heavy load off one’s belief of isolation in the experience of imposter syndrome. We are not in this alone. And we are not imposters.
I now truly believe that I was a good student, a capable resident, and today am a good physician. Not a superhero-like or perfect physician, but one that no longer feels like a fraud, is willing to make mistakes and discuss them with my colleagues, a physician that has taken off the cloak of perfectionism and embraced my humanness.