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ER Goddess

ER Goddess

It's Not Imposter Syndrome—It's Gender Bias

Simons, Sandra Scott MD

doi: 10.1097/01.EEM.0000751840.09985.e0
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    sexism, workplace discrimination, women in EM, imposter syndrome
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    Once upon a time, I believed that I suffered from imposter syndrome. Like so many other high-achieving women, I thought, “Yep. That's me,” when I heard about this phenomenon.

    Imposter syndrome is an experience characterized by persistent doubt about one's abilities and the fear of being exposed as a fraud despite evidence of success. The syndrome more commonly affects women, and it insinuates that any self-doubt we feel is due not to our workplace but to a defect in our psyches.

    The concept of imposter syndrome originated nearly 50 years ago when medicine and other professional arenas were still very much boys' clubs. (Psychother Res. 1978;15[3]:241.) Women have made strides toward gender equality, but we are still inundated with messages that our femininity makes us less worthy of respect. Even in 2021, we are reading #MeToo stories of male physicians sexually assaulting female coworkers while hospitals look the other way. (“Harassment Suit: EP Failed to Report Offender,” EMN. 2021;43[3C]; https://bit.ly/3r6fRxx.) After repetitive exposures to the message that we don't belong at the table, why are we labeled with a syndrome when we unsurprisingly feel like we don't have a rightful seat?

    Perhaps women need to rethink all the self-blame. A recent article in the Harvard Business Review declared that imposter syndrome is a fairly universal feeling of discomfort, second-guessing, and mild anxiety in the workplace that has been pathologized, especially for women. (Feb. 11, 2021; https://bit.ly/3d9pgzF.) The discomfort that women have been convinced is imposter syndrome is not a psychological affliction but a normal response to being female in a culture rife with gender discrimination.

    We like to think that we have learned to ignore subtle instances of disrespect. “Don't worry your pretty little head” was one trivializing comment I recall from residency when I asked the senior surgical resident a question. As these remarks accumulate over our careers, we tell ourselves that we have learned to laugh them off or that they don't faze us. Yet deep down, they seep in, add up, and ultimately affect us. Feelings of self-doubt about our work and intelligence are not due to imposter syndrome; they are the cumulative effect of microaggressions on our professional self-worth.

    Difficult Balance

    “Be a mom, be a wife, be a doctor, but each in its season. Don't expect to do them all simultaneously with expert ability and no pain. It's in very few women's nature,” wrote a male physician in response to an article I wrote about balancing motherhood and medicine. (“Parenthood and Medicine, Each in Its Own Season,” EMN. 2017;39[8]:21; https://bit.ly/3c59syf.)

    Cognitive gender bias means our colleagues and patients may have antiquated, entrenched patriarchal notions that a woman's place is in nonphysician roles. Recently I went to re-evaluate a patient, and he told the person on his phone to hold because the nurse was back. This occurred despite me wearing a white coat and having initially introduced myself as a doctor. Is it any wonder that a woman who is repeatedly assumed to be a nurse would sometimes feel like an imposter as a doctor? Our sense that we don't belong is not imposter syndrome; it's 1940s gender role conditioning rearing its ugly head to make women feel unwelcome in traditionally male roles.

    Even when women are accepted as physicians, we have a narrower window than our male colleagues of what behavior is acceptable. Society expects not only certain gender roles (male doctors, female nurses) but also specific behaviors from different genders (strong men, agreeable women). How do I embody the classically male traits of a leader when the unspoken expectation is that I should be more deferential and less direct because I'm a woman? Feeling like we can't find the sweet spot is not imposter syndrome; it's the normal response to bringing feminine behavior to roles in which accepted styles of leadership are decidedly masculine.

    “If you're going to be wrong, be wrong with confidence,” advised my favorite attending during residency. He was trying to teach me how to be more authoritative in an environment that often rewards assertiveness over knowledge and skill. Being judicious and thoughtful in the ED should not be problematic, but the reality is that women may not be perceived as real leaders if they don't project 100 percent confidence.

    As hospitals chase patient satisfaction metrics, I have female colleagues who have been advised to act less uncertain and more commanding because total self-assuredness, even if unwarranted, is more pleasing to patients. Our hesitation to embrace false confidence is not imposter syndrome; it's normal caution and respect for patient safety, both of which seem devalued by a medical culture that reveres cowboy bravado.

    The Real Problem

    We may be disliked when we present ourselves in a masculine, bold, and decisive way. Assertive men are capable leaders, but assertive women are difficult. If we show even mild anger, we are more likely than men to be viewed as emotionally out of control. The discomfort we feel if we—god forbid—raise our voice is not because of imposter syndrome; it's because we really are perceived more poorly than our male colleagues when we assert ourselves.

    I have received complaints that I wasn't sure enough, and I have heard that I wasn't deferential enough to nurses and registration staff. I received an evaluation in residency, right after I had a miscarriage, that said I wasn't happy enough. Yet I genuinely believe if life had facilitated me being happier and more carefree, I would have received an evaluation that said I wasn't serious enough. The double bind for women of never being just the right combination of confident and deferential, happy and serious means they are frequently criticized and corrected.

    It can feel like male mistakes are tolerated, ignored, and brushed aside—as in the case of recent sexual allegations at Oregon Health & Sciences University—while women are critiqued with a fine-tooth comb. I think the disapproval and resistance we sometimes feel when we're just trying to do our jobs is not imposter syndrome; it's the impossible double bind for female leaders: We're damned if we do and damned if we don't.

    Labeling female physicians as having imposter syndrome may be easier than changing workplace culture, but it inappropriately blames individuals for natural reactions to persistent sexist overtones in medicine. Rather than helping women fight imposter syndrome, we should be fighting gender discrimination. I'd like to see women stop telling themselves, “I have imposter syndrome; I'm the problem.” It's time for more women to change their internal dialogues. We should be telling ourselves, “It's not imposter syndrome; it's gender bias.”

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    Dr. Simonsis a full-time night emergency physician in Richmond, VA, and a mother of two. Follow her on Twitter@ERGoddessMD, and read her past columns athttp://bit.ly/EMN-ERGoddess.

    Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.
    • evanenglish2:29:42 PMHalf the human race for thousands of generations has been deemed lesser in almost all aspects of life. In spite of the fact that everyone has a mother, we somehow have not yet fully grasped how wrong anti-female behavior is. Change has never been so slow.