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The imposter syndrome is well described in medical students. It has been identified in some rather eminent Med Ed journals at least as early as the 1990’s and something with which I could once acutely identify.

Our good friend wiki defines this “Impostor Phenomenon” thusly: “Regardless of what level of success they may have achieved in their chosen field of work or study or what external proof they may have of their competence, those with the syndrome remain convinced internally they do not deserve the success they have achieved and are actually frauds. Proof of success is dismissed as luck, timing, or as a result of deceiving others into thinking they were more intelligent and competent than they believe themselves to be.”

I know that I personally have felt this very strongly in the past. By the end of second year I felt so convincingly out of my place that I was actually worried almost constantly about getting found out. Despite above average marks I was convinced that most students knew much more than me, I avoided going to study groups I was invited to join so as to avoid showing others how little I knew. Even though I did very well in my OSCE and tutor assessments I lived in fear that my tutor at hospital would one day unwittingly expose me to the point where I would dread my one day a week in hospital and feel palpable relief when it finished. In short I genuinely believed I did not belong in med school and had somehow fallen irreparably behind the rest of my cohort. What evidence I based this on is, on reflection, a mystery to me.

I’m not sure quite what caused it, and the literature on this isn’t all that clear either, but there are a few things which think helped me get over it.

• Clinical years. Once your point of reference is a clinician and not a basic scientist, you realise most actually don’t remember in an significant detail the different stages of exocytosis, the differing functions of the medial superior olivary nucleus vs. the lateral superior olivary nucleus or every enzyme in the kreb cycle, it’s not just you.
• Doing better. Pure and simple, I moved from marks slightly above the mean to what could be called “very comfortable”. It’s much easier to feel like you know what you’re doing, when you know more.
• Application. Once I started seeing patients who actually had strokes/AMIs/GNs and realised I knew what was going on it was an entirely new feeling. As long as you’re in preclinical years learning from books with little application of that knowledge, you will always focus on what you don’t know . When you’re learning about things for the first time from books you highlight to yourself just how much you don’t know, when you apply to patients things you already learned you highlight to yourself how much you do.

More testing helps too, or, at least, I think it does. The fundamental problem is an awareness of where I was, in relation to where I was supposed to be. Now we have progress tests three times a year in addition to our summative assessments, to let us know where we are relative to our cohorts. I’m not 100% sure whether embracing these tests helped my impostor mindset or whether the impostor phenomenon abating made me accept these tests. In second year even though I passed exams solidly I was still convinced that somehow I’d fluked or tricked it and would be found out, so this point might not be as clear as it seems.

I would like to say this is something I discussed with my colleagues but I just couldn’t. It’s something I think isn’t talked about, but it’s something which caused great distress to me, I certainly don’t have it now, I’m on a palliative medicine rotation right now and loving it. I find that most of the time I can generally guess what the Drs (if not the patients) will do next, and at the very least at least understand what they’re doing. Beyond that though I find that I still react differently. When I don’t know something, if I see a patient come in on a drug I don’t know, I look it up. In the past I would have assumed everybody knew it but me and hoped I didn’t get found out.

So there’s no impostor syndrome for me right now, I think that’s probably all I can say: “right now”. This is something that caused some serious distress for me not too long ago, and it felt so incredibly, incredibly alone and isolating when it did. If you feel this way, and the literature suggests at least some of you will soon enough, remember that medicine is a hard slog and people won’t look down on you if you admit you feel out of your depth, because chances are they have to at some point.

 - Over and Out

P.S. Here’s a reference for the first sentence: Henning K, Ey S, Shaw D. Perfectionism, the imposter phenomenon and psychological adjustment in medical, dental, nursing and pharmacy students. Med Educ 1998;32:456-64.

P.P.S. On a final side note I was speaking to a senior specialist physician today, who has some rather exalted roles, about what I was going to post about in this blog tonight, and when I mentioned this I was at least mildly surprised to hear they, and many of their colleagues experience the exact same thing, both in academia and senior clinical roles, so it’s something that probably effects people at all levels, just thought that was interesting.