Impostor Phenomenon (aka Impostor Syndrome) in Medicine, Part 1

Throughout the rest of January, we will tackle the topic of impostor phenomenon, aka impostor syndrome. Today we will mainly unpack the definition, look briefly at demographics, how it shows up, and some key points from my perspective. We will unpack why it matters and practical steps to gain some relief in the following weeks. Finally, we will discuss tips for interacting with those experiencing intense impostor symptoms.

So, what exactly is impostor phenomenon (IP)? Essentially IP is a severe thought distortion in which an individual dismisses their inherent abilities, skills, or talents and attributes their successes to other factors – luck, a mistake, someone calling in a favor, personal charm, etc. They then live in fear of being discovered to be a fraud and hide behind a persona involving perfectionism for protection.

Working with family medicine residents, faculty, and early career physicians, I often hear clients admit they feel like frauds. There is a firm belief that they’re not as intelligent or skilled as people give them credit. They feel the need to prove themselves to keep up the charade and often measure themselves against the yardstick of perfection. They hide their insecurities as they wouldn’t want the others in the program to know the “truth” about themselves. Sound familiar?

Dr. Clance and Dr. Imes, psychologists who defined the phenomenon in the ’70s, described a cycle of IP. A task arises -->the person reflects on their lack of skill or intelligence --> they fear failure and being exposed --> they become immobilized either by procrastination or sidetracked with over-preparation --> they perform last-minute panicked work --> they have success --> they either dismiss it altogether or have short-lived fleeting happiness.  They never internalize the success or experience fulfillment. They see the overworking as evidence they aren’t naturally smart or deserving. They have reinforced their belief about themselves. The cycle starts again with the next task. 

Dr. Jennifer Hunt describes five dysfunctions of IP: My take of those are 1. Emotional Dysregulation - either emotional outbursts or internal flooding of emotion; 2. Inner Critic Amplification - we’ve talked about this a few times in our blog; 3. Self-sabotage - when you overdo one of your strengths, making it a saboteur. An example could be a person who has good attention to detail becoming a stickler; 4. Masking for Perfection -hiding behind a performance-based persona or avatar, and 5. Feedback Distortions -in which positive feedback is dismissed, and constructive is seen as negative and magnified. She cites some statistics in family medicine residents, in which 1/3 at the time were actively experiencing IP side effects. 

According to Drs. Lisa and Richard Orbé-Austin, more recent studies  IP occurs in up to 70% of the population at some point in their lives.  And up to 50% of the high-achieving population experience IP behaviors and feelings almost weekly. It occurs equally across the genders in their research, though Drs. Lisa and Richard Orbé-Austin found that it manifests differently between men and women (more on that next week). They also found in their research that underrepresented minorities experience a “double-impact” in which their IP gets reinforced not only by their own thoughts but also by the culture that they’re in. They are told in various manners they really aren’t qualified for the job. This leads to further negative impact with the Stereotype Threat described by Steele in 1995. And we have also learned how some individuals in societally-disempowered groups don't have IP at all, but they are made to feel that way. Researcher and psychologist Kevin Cokley recently broadened the definition to include not just the individual but the system that sets individuals up for feeling like an imposter. He and other contemporary reseachers coined the term Racialized Imposter Phenomenon as persistent beliefs or actions of intellectual and professional self-doubt among racially minoritized people due to experiences, systems, or principles of racial oppression and inequity. You can likely see how this concept can apply to other domains outside of race, as well, in which the structures that people operate within.

There are a couple of things I’d like to highlight:

1. Impostor phenomenon is not the run-of-the-mill self-doubt that almost all humans experience on the regular. While IP is common, recently, the term has been cavalierly thrown about and used to label nearly every situation in which a person doesn’t have 100% confidence.

2. It is also not a personality trait. We would never want to attribute any other thought distortion to a person’s intrinsic makeup. Therefore, the person experiencing IP, and those observing it, must use care not to use the label of impostor as an identity.

3. I really prefer the term “impostor phenomenon” (IP) as initially described instead of “syndrome,” even though the latter has become the current social trend. Clance and Imes specifically avoided the word “syndrome” because it’s not a psychological diagnosis. The word syndrome, especially in medicine, connotes a diseased state. The person who experiences IP is not diseased or broken. They are experiencing a common phenomenon.

4. There is a gradient. You can self-score on the validated Clance Impostor Phenomenon Scale (CIPS). The score gives a number on a scale of how many IP tendencies you have: Few IP tendencies (no to minimal impact), Moderate IP tendencies (moderate implications and may affect some decisions or results), Frequent (affects many choices and results in several areas), Intense characteristics (affects most aspects of life and can feel debilitating).

^{Clance Impostor Phenomenon Scale (CIPS).  From The Impostor Phenomenon: When Success Makes You Feel Like A Fake (pp. 20-22), by PR Clance, 1985, Toronto: Bantam Books. Copyright 1985 by Pauline Rose Clance, Ph.D., ABPP. Use by permission of Dr. Pauline Rose Clance. Do not reproduce/copy/distribute without permission from Pauline Rose Clance, [email protected], www.paulineroseclance.com}

5. Impostor phenomenon waxes and wanes across a lifetime. It’s often triggered by specific situations, settings, or people. It occurs more frequently when attempting new things, assuming new roles, or other conditions when insecurities flare.   
6.  You cannot ever TELL someone they are experiencing it. It's an internal perception. From the TED talk by Dr Catherine Toomer, to the HBR article, the New Yorker article, and the 2023 Smith College commencement speech - many individuals, especially women or historically marginalized individuals, are hearing that they have impostor syndrome when in fact, they're striving to prove themselves as society isn't making room for them to belong, which is quite the opposite.

For this week, I ask you to reflect on yourself. Take the CIPS. Reflect and see if you can identify triggers of your IP tendencies and think back to your first memories of having this pattern. 

Next week, we will dig a little further into why it matters.

Have a joy-filled week!

Tonya

Residency programs can benefit from our Flagship 6-week hybrid coaching course for resident or faculty groups. Learn more here 

Original post 1/2022, updated 3/2024