Overcoming Imposter Syndrome as a New Fellow

Welcome to fellowship! You have mastered the art of internal medicine, served as the senior resident for a medicine team, and perhaps even served as a chief medical resident. Now you are a fellowship “frosh,” and are suddenly being called in the middle of the night to help a patient with hemophilia suffering with a complex bleed. You think, “Am I in over my head? Do I deserve to be here? Am I qualified?”

The short answer to all of those questions is yes. However, the answer we often say to ourselves in new situations is no.

What is imposter syndrome? Harvard Business Review recently published an article noting that “imposter syndrome is loosely defined as doubting your abilities and feeling like a fraud.”1 Although uncertainty is normal in a new situation, imposter syndrome reflects an underlying cognitive distortion. This is distinct from the feeling of being a novice, or someone who recognizes a steep learning trajectory as a part of skill acquisition. I have overheard fellows use the term “imposter syndrome” when talking about their worthiness for a job, worthiness to sit on professional society committees, worthiness to apply for competitive workshops, or even worthiness to provide a clinical opinion.

How do we address this feeling of “less than” and “unworthiness?” How do we embrace the concept that even our best selves are a work in progress and that we are worthy of opportunity and subsequent growth? How do we recognize that uncertainty can be a good thing as it provides a source of motivation to learn new skills and content? How do we recognize that humility is wonderful but should not interfere with our confidence?

Sometimes things are easier said than done. Think about the following reframing steps when you feel imposter syndrome creeping in. You can use these steps when confronted with an event, or you can reflect on an entire day in order to help reframe any “stinking thinking” that undermined your confidence.

We will use the framework of the aforementioned case.

You’re a first-year fellow. You’re called at night for a consult by neurosurgery on a hemophiliac who needs urgent surgery because of a subdural hematoma. You know that you’re supposed to give antihemophilic factor, but you freeze and don’t know where to start. You are very uncomfortable with the situation and have the following thoughts:

• I am stupid. I should know this already. I am behind.
• If I call the attending, they will know that I am inferior to other fellows and may think I am stupid.
• I am not smart enough for this fellowship. They will realize that they made a mistake when they accepted me.

1. Separate Feelings From Facts

Identify the factual issues that are creating your anxiety. Make an objective analysis of your situation. Do not insert your feelings and do not mistake feelings for facts. For example, if you are the first-year fellow noted above, your anxiety and feelings of inferiority may be derived from the following facts:

• You do not have a mastery of knowledge in this area.
• You are fearful of asking the attending on call a question.

Taken together, you have become a victim of cognitive distortion. By assessing the situation objectively, you can identify how to extricate the feelings from the facts. Your anxiety is rooted in your assigned negative perception of your abilities, but the reality remains that you are a new learner, and you are in the fellowship to learn. If you knew everything already, you wouldn’t be a fellow.

Although you may not have the opportunity to self-reflect in the acute situation, these principals can be applied at any time.

2. Identify Data

An important component of self-reflection is the ability to recognize the areas in which objective data about your performance exists and to learn how to use that data to improve. For example, if you are a third-year fellow and don’t know where to start when treating a patient with hemophilia, then your concerns about your ability to practice independently soon may be valid. That still does not mean you are an imposter. Data can be your friend.

Rather than reinforcing a feeling of incompetence, data provide a map to plan a path to proficiency. Examples of data include questions missed on the in-service exam, milestone assessments, and faculty feedback. This allows you to identify areas in which you need to concentrate. Remember that these sources of data were built to help an individual grow professionally. In fact, data assume that you are worthy and able to utilize the information in a meaningful way as you master your craft. You can improve. You are a learner rather than an imposter.

3. Befriend Yourself

What would you say to a friend in the same situation? Why do we allow ourselves to trash-talk ourselves, but extend grace and empathy to a colleague in the same situation? The most important friend we need to comfort, encourage, reframe, and look objectively is ourselves.

4. Avoid Binary Thinking

We tend to think in binary terms—something is either all good or all bad. Even on a milestones rating scale for training, an individual trainee may assign “good” or “bad” to their milestone score. Keep in mind that even the milestones measures are meant to be a trajectory—you’re striving for progress, not perfection. Although it is healthy to ask, “How can I improve?” that is a very different conversation from, “I am bad.” You are all high achievers. You would not be in your current positions otherwise. That said, everyone will not score a perfect 5 out of 5. I urge you to embrace your imperfections—your “humanness”—as a key to avoiding imposter syndrome. Reframed uncertainty and imperfection are prizes in and of themselves. It is a blessing that provides all of us with the chance for personalized learning, academic growth, professional evolution, and the ability to flourish.

Reference

1. Tulshyan R, Burey JA. Stop telling women they have imposter syndrome. Harvard Business Review. February 11, 2021. Accessed July 22, 2021. hbsp.harvard.edu/product/H066HL-PDF-ENG