Originally described by Drs. Pauline Rose Clance and Suzanne Imes in 1978 [1], the impostor phenomenon is slowly gaining recognition in academic medicine, although it has been better studied in other fields, such as psychology and business. The impostor phenomenon is a psychological construct (not a clinical syndrome, per se) which may be encountered in high achievers who believe that others overestimate their skills and abilities. Individuals with this phenomenon have a persistent tendency to attribute their successes to external factors (such as luck) or to disproportionate effort and believe that they will soon be “found out” to be less competent than they appear [1]. Up to 70 % of successful people in the USA may have impostor feelings, according to Dr. Clance’s landmark work, The Impostor Phenomenon ([2], p. 97). This construct was initially thought to be more prevalent in women, although recent studies have shown less marked gender differences [1, 2]. On one hand, the impostor phenomenon may have a positive impact on one’s productivity, by driving superior achievements; on the other hand, it can be associated with a series of counterproductive behaviors, ranging from maintaining a low profile to self-sabotage and acting out. Psychiatrists are often at the forefront of educational reform in academic health centers and, in this role, may be in a position to effect institutional culture changes. As will be discussed below, the impostor phenomenon may have deleterious effects on faculty, staff, and trainees’ mental health. Academic leaders who develop wellness or academic support programs may want to become familiar with this phenomenon and its potential negative consequences, so they can readily identify and address these.

A PubMed search with the search terms impostor phenomenon and impostor syndrome revealed scarce findings. Additional articles were retrieved from Dr. Clance’s website (http://www.paulineroseclance.com/) as well as manual search of references listed in review articles. Few studies have explored the impostor phenomenon among health care professionals or trainees, and none to date has focused on academic physicians [3–5]. The Clance Impostor Phenomenon Scale (CIPS) is a validated instrument for assessing impostor phenomenon characteristics, which consists of 20 questions rated on a Likert-type scale from 1 to 5 where 1 = not at all true and 5 = very true [2]. Scores higher than 62 are considered relevant [1], and this cutoff was used in all three studies discussed below [3–5]. Henning and colleagues [3] administered the CIPS to 477 medical, nursing, dental, and pharmacy students. Approximately a third (27.5 %) of the participants reported high psychiatric distress levels as assessed through the Brief Symptom Inventory, which strongly correlated with CIPS scores [3]. This study also found that high CIPS scores were associated with perfectionism, and significantly more women than men scored above the cutoff [3]. In a survey of 185 family medicine residents [4], 41 % of women and 24 % of men had high CIPS scores, which correlated with anxiety and depressive symptoms. Additionally, in a study of 48 internal medicine residents from Canada [5], CIPS scores negatively correlated with the Maslach Burnout Inventory personal accomplishment subscale (low scores on this subscale indicate high burnout levels). Female residents had significantly higher CIPS scores than their male colleagues, consistent with previous studies in the health care professions. This is the only study published to date that specifically examined impostor phenomenon feelings in international medical graduates (IMGs). All but one (86 %) of the IMGs had high CIPS scores, compared with only 36 % of the Canadian residents [5]. As a group, IMGs also had higher average CIPS scores than their Canadian counterparts (78 vs. 58) [5].

Contributory Factors

The origins of the impostor phenomenon are fairly well understood and can be best described as multifactorial, with demographic, familial, and environmental contributors [2, 6].

Demographic factors include race, ethnicity, gender, socioeconomic-cultural background, and immigrant status. For example, students, residents, and faculty from underrepresented minorities in medicine have few role models of similar backgrounds. They may constantly feel inadequate, because it is hard to establish criteria for success applicable to their specific situation. This is also true of women in the fields of science, technology, engineering, and mathematics, as well as health care. Some students are the first in their family to go to college or medical school, which may lead to immense pressure to succeed while also creating unconscious guilt and fear of success. Success may indicate that an individual has surpassed one’s parents and many other members of his or her community, conflicting with spoken or unspoken taboos [2]. Cultural factors may also play a role, because different cultures have varying expectations and definitions of success. Individuals who study or work in a different country (i.e., foreign-born graduate students or IMGs) are at high risk for impostor phenomenon due to differences among academic and health systems and constant pressures to adapt to their new environments, where they may feel they have a very low margin of error in order to be accepted [5].

Familial factors contributing to impostor feelings include high parental expectations and early messages communicated to children of either inadequate validation or excessive praise [2, 6]. In turn, these relational patterns may lead to individuals feeling that they always have to be perfect in order to gain approval or believing that they have no room for failure, because they have always done things well (e.g., growing up, they were usually seen as gifted). Several studies have found that first-born children are at higher risk of developing impostor phenomena [6]. Children whose interests greatly differ from those of their family (e.g., the only scientist in a family of artists), dubbed by Dr. Clance as “the square peg,” may also be more prone to it [2]. Additionally, children of highly successful parents may experience significant self-doubt and pressure to perform, wondering if they can measure up, and this can engender impostor feelings [2].

Environmental factors are ubiquitous in any higher education program and include learner status (e.g., being a “serial novice” with every step of training: student, resident, fellow, or junior faculty); being surrounded by equally driven, bright, and accomplished individuals (in academia, by definition); and being constantly evaluated (e.g., medical students on clinical rotations or strict promotion criteria for faculty members) [2]. Impostor phenomenon characteristics may reemerge at times of transition in professional development, with promotions or new assignments for faculty members or even new roles outside of work, such as becoming a parent [2]. Even though promotions usually indicate that individuals are recognized for their work, those suffering from the impostor phenomenon will feel inadequate and work hard to prove themselves all over again. They will invest a great deal of effort, often out of proportion to the task at hand and to the detriment of other areas in their life, in order to make sure they succeed and thus avoid being discovered as “impostors” unqualified for the job.

Associated Behaviors

The impostor phenomenon may be associated with a number of behaviors that are mostly unconscious attempts to compensate for the deeply held beliefs of inadequacy. Dr. Valerie Young calls these behaviors “hiding out” [7]. Individuals may maintain a low profile and decline additional duties, doing their best to “fly under the radar” [2, 6, 7]. Their persistent fear of failure may translate into deferring promotions, turning down assignments that would increase their visibility or lateral transfers between institutions, to avoid positions of increasing responsibility. Perfectionism, often associated with impostor traits, may lead to an inability to make decisions, which can ultimately be paralyzing. Because perfectionism partially overlaps with impostor characteristics, it is important to distinguish the two profiles. The main difference is that those with the impostor phenomenon are less able to internalize successes, whereas perfectionistic individuals typically feel validated by achieving their goals.

Procrastination is also part of the impostor phenomenon picture, typically manifested by starting to work on projects or preparing for exams at the last minute. As Dr. Young [7] explains, procrastination offers an excuse: if the project fails (or if one scores low on an exam), individuals with the impostor phenomenon may feel “disappointed, but hardly surprised” because they know they did not really give it their all. Procrastination may combine with perfectionism, resulting in an inability to finish assignments and projects [6]. Academic psychiatrists, especially those who mentor more junior colleagues, should pay attention to this aspect of the impostor phenomenon, because it can severely limit their mentees’ scholarly productivity and, hence, hinder promotion. In extreme cases, self-sabotage may occur [7, 8]. In students, this can be manifested by chronic lateness, missing deadlines, late payment of fees, or not taking board examinations on time, despite serious disciplinary actions imposed by schools [8]. More serious self-defeating behaviors may include acting out sexually or substance use [6].

Consequences

A variety of consequences may result from the impostor phenomenon in academic psychiatry, affecting individuals, their families, coworkers, team members, and institutions. Although struggles in work-life balance are pervasive throughout academia, those with the impostor phenomenon are at special risk for the balance tipping toward persistent workaholism. Burnout, anxiety, and depression may occur, as discussed above [3–5, 7]. In its most severe manifestations, in combination with isolation and fear of failure, the impostor phenomenon can contribute to suicidality.

From an institutional standpoint, those with impostor feelings can have difficulties leading workgroups and teams due to their inability to delegate, as well as the tendency to micromanage and set impossible goals for their teams [6, 7]. They may also operate as “masters of catastrophizing,” who postpone the delivery of projects due to the need to plan for all possibilities, combined with their inability to finalize decisions. This may lower other employees’ morale, as they become affected by the poor leadership, micromanagement, and procrastination. Clinicians with the impostor phenomenon may rely too heavily on consultants to assuage their self-doubts about the management of clinical cases, which may result in delaying appropriate care and ultimately contribute to poor patient outcomes.

Strategies to Combat the Impostor Phenomenon

Table 1 presents several strategies for individuals and institutions to use in addressing the impostor phenomenon [1, 2, 6–9]. These strategies parallel the contributing factors and associated behaviors described above. Individual strategies range from basic techniques informed by cognitive-behavior therapy, such as learning to accept positive feedback and developing supportive mantras, to individual and group psychotherapy. Individual therapy is highly recommended to uncover and understand one’s unconscious reasons for self-sabotage. A thorough psychiatric assessment may also be indicated to identify and treat any underlying mental health difficulties.

Table 1 Suggested strategies for addressing the impostor phenomenon [1, 2, 6–9]
Full size table

Institutional strategies may include educational workshops for medical students and residents, with the goal of being able to identify impostor feelings as they occur and being prepared to address them. Given the fact that IMG trainees are at higher risk of developing the impostor phenomenon, targeted education and mentorship programs might be helpful. Additionally, informing all medical educators of this constellation of traits and its associated behaviors is crucial. Faculty members who design academic or professionalism remediation interventions need to be aware of self-sabotage, for example, because remediation plans will differ depending on the root cause of the unprofessional behavior or academic failure.

Academic health centers are encouraged to reevaluate their institutional cultures and make sure they do not maintain counterproductive attitudes focused on punishing mistakes, which can exacerbate impostor feelings in their employees. Instead, a growth mindset (e.g., treating errors as learning opportunities) will help individuals become superior contributors and allow institutions to better adapt to the fast-paced changes of the current health care landscape.

Implications for Educators

• Impostor phenomenon can affect individuals at all medical education levels, from students to deans.

• It is important to identify and provide support to those with impostor feelings, given the impact on individuals, their families, teams, and institutions.