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After the Match

Psst, Residents

It's OK to Have Imposter Syndrome

Cook, Thomas, MD

doi: 10.1097/01.EEM.0000550376.43438.4e
After the Match

Dr. Cook is the program director of the emergency medicine residency at Palmetto Health Richland in Columbia, SC. He is also the founder of 3rd Rock Ultrasound (http://emergencyultrasound.com). Friend him at www.facebook.com/3rdRockUltrasound, follow him on Twitter @3rdRockUS, and read his past columns at http://bit.ly/EMN-Match.

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I was sprawled out on a grass field, the metallic, salty taste of fresh blood sloshing in my mouth. Loose teeth shifted in my fractured mandible after I crashed into one of my fraternity brothers during an intramural football game. My first thought was how upset my mother would be that I had ruined all the expensive orthodontic work she paid for with her meager salary. The second was how I could possibly interview for medical school in two days. My jaw was crushed, along with the slim hope that I would become a doctor.

I made it to the interview with a head swollen as big as a basketball. I drank my lunch through a straw and tried to formulate cohesive answers to puzzled interviewers.

Back in my dorm room, I got a call from my mother about a letter that had arrived that afternoon from the medical school. I was accepted less than 24 hours after I had finished interviewing. They must have put the letter in the mail as I was leaving town. How did this happen? I was a B+ student. Nothing spectacular. It did not make sense. The only logical explanation was that they felt sorry for me.

My life has been a study in mediocrity. I was an above-average college student who became an average medical student at an average medical school. I entered a relatively uncompetitive specialty (at the time) and trained with average medical school graduates in an average residency program in the middle of nowhere Texas. Nothing about my career is superlative. Nonetheless, a small number of people in health care seem interested in my lectures and writing. I am puzzled by this. Why would anyone want me to tell them how to manage patients? In a profession filled with difficult and occasionally life-saving decisions, am I really the best person to do this?

Consider the following questions:

  • Did you experience anxiety or depression about your grades, clinical evaluations, or letters of recommendation?
  • Have you been referred to as a “perfectionist?”
  • Do you excessively self-monitor your performance or scrutinize your self-worth?
  • Do you think your success is largely due to your fortunate access to a great education or excessive luck compared with others?
  • Do you find yourself wondering why patients, peers, and even attendings believe you actually know what you are doing and value what you have to say?
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Vicious Cycle of Guilt

If you are an emergency medicine resident, it is very likely that your answer to several of these questions is yes. Sitting in my office behind a closed door, some of the most talented, unflappable residents will confess how anxious they are about what the faculty and their peers think about them. The list of anxiety-laden questions is long: “Do others think I know what I am talking about?” “Do they think I am a hard-worker?” “Am I ready to work alone?” “Am I ready to moonlight?”

Estimates say that 70 percent of accomplished professionals experience or continuously have doubts about their accomplishments and excessive concern about being perceived as incompetent. (Int J Behav Sci 2011;6[1]:75; http://bit.ly/2yAc5TO.) They often experience guilt and fear of additional success because it creates a vicious cycle of more guilt. They question why they are more fortunate than others who are just as talented. Physicians are perfectly set up for the phenomenon called imposter syndrome.

This syndrome is not a mental disorder, and it is not listed in the DSM-5. People with mental disorders such as depression and anxiety may be more susceptible to it, however. (Int J Behav Sci 2011;6[1]:75; http://bit.ly/2yAc5TO.) New work environments, academic settings, and relationships based on living up to the expectations of others are all components of residency training that put young physicians at risk of this syndrome.

But residents are not the only ones who struggle with these feelings. Older emergency physicians must contend with smart young doctors filtered by the match into one of the most competitive specialties. Their younger brains are sponges that soak up information from off-service rotations, blogs, and podcasts, while the brains of older physicians are slowing down and burdened with decades of memorized information no longer relevant to current practice.

You are not alone if you find yourself questioning your ability. The majority of highly successful people will worry about their ability and expertise, particularly when they fail (as everyone does). The list of famous, highly successful people who have experienced feelings consistent with imposter syndrome include actors, artists, musicians, business leaders, billionaires, and Supreme Court justices.

Accepting how common these feelings are within groups of highly successful people is critically important. I have seen older EPs encounter and eventually accept their scholastic and professional limitations. No one knows it all, and all of us have weaknesses. Getting hung up on the need to be the best is unsustainable, and finding some measure of peace with your own shortcomings is imperative to maintaining your mental health over a long career.

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