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A Piece of My Mind
August 6, 2019

Imposter Syndrome: Treat the Cause, Not the Symptom

Author Affiliations
  • 1Division of Healthcare Delivery Science and Innovation, Weill Cornell Medicine, New York, New York
  • 2Department of Medicine, New York-Presbyterian Hospital, New York
  • 3Department of Radiation Oncology, Michigan Medicine, Ann Arbor
  • 4Center for Bioethics and Social Sciences in Medicine, University of Michigan, Ann Arbor
  • 5Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
JAMA. 2019;322(5):403-404. doi:10.1001/jama.2019.9788

A few weeks ago, a Twitter account called @womeninmedchat facilitated an online conversation about imposter syndrome in medicine. Imposter syndrome is a psychological term that refers to a pattern of behavior wherein people (even those with adequate external evidence of success) doubt their abilities and have a persistent fear of being exposed as a fraud. Online, there were numerous responses: women talked frankly about how they attributed accomplishments to luck or good timing instead of merit, voicing fears that they had simply duped others with an illusion of competence.

The sheer prevalence was emphasized by an aspiring surgeon: “I’d like to meet someone who HASN’T experienced imposter syndrome.” Others highlighted how the syndrome disproportionately affects women and minority groups—who often lack sufficient role models of success. Many reported that it led to meaningful setbacks in their careers, from being too paralyzed to speak up at meetings to not asking for opportunities or promotions due to feeling unqualified. An academic hospitalist wrote, “There are invisible gates or wormholes to better career possibilities. Having imposter syndrome means you will miss the gate when someone asks you if you’re ready or interested in something.”

As we round the corner from #MeToo, which helped bring the scope and severity of sexual harassment and gender inequity to the forefront of public consciousness, and begin the process of quality improvement that is advocated by movements such as TIME’S UP Healthcare, one might wonder if spotlighting the widespread issue of imposter syndrome detracts from these movements’ messages. Unlike sexual harassment and discrimination, imposter syndrome initially feels like a problem that is internal to an individual’s psyche, a self-inflicted wound. In this way, the problem begins and ends with the affected person taking an inward look and pursuing a “fix.”

Much of the existing narrative around imposter syndrome focuses on individual fixes. Online, articles often attribute the origin of the syndrome to character traits like perfectionism.1 In one qualitative study, physicians characterized medicine as an elite profession populated by high achievers who were particularly susceptible to linking their self-worth with achievement.2 Consequently, remedies such as maintaining diaries of accomplishments or pursuing self-care with mindfulness and meditation proliferate in seminars and self-help blogs.

But is this the right approach? Imposter syndrome, in many ways, is analogous to another, related, epidemic—that of clinician frustration—often termed burnout. Studies show that a third to half of medical students and clinicians are experiencing depression and anxiety, much higher rates than those observed among their nonphysician peers. A single such affected physician can be prescribed medication, encouraged to seek talk therapy, or asked to take a therapeutic leave of absence. But at the aggregate level, administrators are acknowledging that they have a part to play in addressing the structural environment—long hours, rising caseloads, and an increase in administrative tasks related to electronic medical records, which can contribute to frustration. As the syndrome of frustration and “burnout” gains increasing recognition in the public forum, the onus of working toward a solution shifts from the individual to the group.

In the same way, imposter syndrome might be viewed less as a personal challenge affecting a few than a systemic problem of considerable scale with real, detrimental consequences to those affected. As such, it constitutes a problem to be confronted at the organizational level with serious engagement from leadership and investment in both cultural transformation and policy change.

Organizations can work to nourish the careers of both men and women by recognizing the subtle ways in which women are socialized to behave in public spaces that can prevent them from being recognized for their contributions. Data show that women are socialized to frame their suggestions as questions in order to garner consensus, to avoid seeming abrasive.3 Other studies show that women can be penalized for exercising power and volubility in meetings, whereas doing the same has a strong, positive effect on men.4 An important research article demonstrated that women tend to minimize their ambitions and salary expectations in mixed-gender environments to boost relationship prospects.5 These learned behaviors ultimately contribute to a self-perpetuating cycle: by softening their edges, women may not be recognized for their competence and therefore not be promoted. But this oversight then leads to women doubting their capabilities and deepening a sense of imposter syndrome. Health care organizations seeking to promote individuals of all genders and racial backgrounds need to be proactive about setting rules and norms that recognize women for excellent work, aim for pay parity, and allocate resources toward leadership training for women and minorities. Organizations must also develop mechanisms by which they repeatedly reevaluate their progress toward these goals.

Additionally, cultural change needs to be paired with concrete commitment to mitigate the root causes of imposter syndrome. Many participants in the Twitter forum discussed the relative dearth of strong female role models, mentors, and sponsors in their workplaces—role models to inspire, mentors to guide and advise, and sponsors to offer opportunities (even when the individual does not herself believe she is qualified!). The data show that women tend to do well in more purely meritocratic environments, such as college and medical school.3 But the real world requires a certain “hustle” to achieve success—knowing people, having name recognition, putting oneself up for opportunities—and the structural barriers are higher for women. This can lead to real exclusion from collaboration and career advancement opportunities. Some academic medical centers are recognizing that highly qualified women may escape search committees’ radar screens, which are typically populated with those with the confidence or connections to gain notice. Simple approaches like the National Football League’s “Rooney rule” that requires that minority candidates at least be included among those considered for a senior position may be a way to combat the bias that may otherwise affect candidate pools and ultimately help remedy the disparity in the leadership pipeline.6 Improving diversity in senior positions is important for many reasons, and one key reason is to provide the role models needed to encourage the increasingly diverse student body entering medical schools today.

Imposter syndrome is but a symptom; inequity is the disease. Promoting equitable representation of women and minorities among the leaders of medicine through concerted systems-level intervention is the most appropriate treatment.

Section Editor: Preeti Malani, MD, MSJ, Associate Editor.
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Article Information

Corresponding Author: Reshma Jagsi, MD, DPhil, Department of Radiation Oncology, University of Michigan, 1500 E Medical Center Dr, UHB2C490, SPC 5010, Ann Arbor, MI 48109-5010 (rjagsi@umich.edu).

Conflict of Interest Disclosures: Dr Jagsi reported that she has received grants from the National Institutes of Health, the Doris Duke Charitable Foundation, and the Komen Foundation; grants and personal fees from the Greenwall Foundation and Blue Cross Blue Shield of Michigan for the Michigan Radiation Oncology Quality Consortium; personal fees from Amgen; and support from Equity Quotient; and reported being a founding member of TIME'S UP Healthcare. No other disclosures were reported.

Additional Contributions: We thank Priyanka Chugh (Johns Hopkins University), Devika Das (University of Alabama at Birmingham), and Vineet Arora (University of Chicago) for letting us share their tweets and insights for this essay. They were not compensated for their help.

References
1.
Corkindale  G. Overcoming imposter syndrome. Harvard Business Review blog. https://hbr.org/2008/05/overcoming-imposter-syndrome. Posted May 7, 2008. Accessed July 8, 2019.
2.
LaDonna  KA, Ginsburg  S, Watling  C.  “Rising to the level of your incompetence”: what physicians’ self-assessment of their performance reveals about the imposter syndrome in medicine.  Acad Med. 2018;93(5):763-768. doi:10.1097/ACM.0000000000002046PubMedGoogle ScholarCrossref
3.
Johnson  SK. What the science actually says about gender gaps in the workplace. Harvard Business Review blog. https://hbr.org/2017/08/what-the-science-actually-says-about-gender-gaps-in-the-workplace. Posted August 17, 2017. Accessed July 8, 2019.
4.
Brescoll  V.  Who takes the floor and why: gender, power, and volubility in organizations.  Adm Sci Q. 2011;56:622-641. doi:10.1177/0001839212439994Google ScholarCrossref
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Bursztyn  L, Fujiwara  T, Pallais  A.  “Acting wife”: marriage market incentives and labor market investments.  Am Econ Rev. 2017;107:3288-3319. doi:10.1257/aer.20170029Google ScholarCrossref
6.
Knoll  MA, Glucksman  E, Tarbell  N, Jagsi  R.  Putting women on the escalator: how to address the ongoing leadership disparity in radiation oncology.  Int J Radiat Oncol Biol Phys. 2019;103(1):5-7. doi:10.1016/j.ijrobp.2018.08.011PubMedGoogle ScholarCrossref
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    1 Comment for this article
    We almost all had imposter syndrome
    Dan Field, MD | MDstaffers
    I am a male without any desire for perfection who got into what was rated as the 3rd best medical school in the country (1979). It was a crapshoot ( > 4000 applicants for 70 spots) to get into medical school and so it seems like it goes without saying we all felt undeserving. More than 30 years later I still suffer from impostor syndrome even as I refuse to let it interfere with achieving my goals.
    CONFLICT OF INTEREST: None Reported
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