Personal Story (Huw)
It was a cold winter evening, hundreds of miles from home, and I was devastated.
I’d just bombed it.
The sub-speciality interview I’d waited my entire career for… and it had bombed. The guilt was the first thing that hit me – my family had sacrificed so much for me to get to this point, and it was all for nothing. I’d spent days reading, thousands of pounds on courses, and travelling to international conferences, and I spent the last six weeks thousands of miles away from my ever-supportive wife and young daughter due to the sad passing of my father-in-law. Nothing could make up for the time missed with them. Or with him.
Then, self-doubt kicked in. Was I ever any good at this? I’d read all the books and spent years studying ventilators, cardiac conditions, the use of inotropes, how CVVH works, and even how ECMO works, and did anybody even notice? To quote one consultant, “Maybe I should just do something else?”
It was the darkest point of my career. I didn’t know where to go from here. I was lost. It was my wife who, despite being emotionally drained from what she had just gone through, picked me back up again. She encouraged me to speak to Ian Sinha, a respiratory consultant, who had approached me out of the blue to offer his help (despite having never worked for him) with my application form and interview preparation. He read through my application the week before submission despite being on holiday with his family at Disneyland – what a human being!
Other people helped me who also didn’t need to – the Liverpool Women’s neonatal consultants set up an interview panel for me. Consultants at Alder Hey spent afternoons and evenings firing questions at me. Their kindness ultimately got me my sub-speciality job. It will never be forgotten.
Personal Story (Siew Yee)
Small details are important when working in tertiary neonatal intensive care and providing care to the sickest neonates in the region. Predicting what you must deal with on any given day is impossible. Will it be the delivery of a 24-week extreme preterm infant, a baby with congenital heart disease, or a critically unwell baby transferred from a district hospital? The constant beeping from all the infusion pumps set up by the extremely dedicated nursing team and intermittent alarms from the monitoring screen seem to have been part of my life over the past six months.
Most junior doctors feel emotionally and physically drained by a 12-hour on-call shift, but this shift greatly impacted me.
It was late, and I was reviewing a baby. They were just a couple of days old and had been born prematurely. They weighed just over 600g – just a bit more than a loaf of bread. He’d had a rocky start. His mother was very poorly in adult intensive care, but this tiny human had the will to fight, and she had been stable over the past couple of days. The nurses told me that evening that he had not quite been himself. He had been very quiet and had become very twitchy. When I got close to the incubator, a sense of foreboding overcame me – he was having subtle seizures. I felt his fontanelle – it was big and tense.
I contacted the on-call consultant, and the nursing team quickly drew up the anti-epileptics. I quickly wheeled over the ultrasound machine to do a bedside scan of his head. I showed the images to the consultant and neonatal team. We all sighed deeply and had the same thoughts at the back of our minds. The little one had a large intraventricular haemorrhage with dilated ventricles.
The first thing that struck me was, had I missed something? Did I not act quickly enough? Was the child on the right antibiotics? The sense of guilt and self-doubt quickly drowned my mind. When we handed care to the day team, I was not emotionally ready to leave the unit. Everything had become uncertain to me. Will this little one ever get to meet her mother? Will he get to live a normal life? Is he still in pain? Had I done everything I should have done?
As a junior doctor, there isn’t a single day when I don’t question whether I have done enough for my patients. Have I selected the right medication? Is this the right conversation to have with their family?
A very kind and intelligent consultant reassured me that all these uncertainties and feelings of self-doubt prevent us from making silly mistakes. We would have considered every option available.
What is impostor syndrome?
Imposter syndrome—the fear of being exposed as a fraud as expectations and responsibility increase—is common in medicine. Up to 70% of the general population experience it at some point in their careers. Clance and Imes originally described it in high-achieving females in 1976, but it is now clear that people from all genders and backgrounds are affected.
It should come as no surprise that imposter syndrome is common in medicine. As junior doctors, we have to move through rotations in different specialities, be asked difficult questions by seniors, and be expected to suddenly become adept at performing procedures and managing wildly different patients. The luxury of feeling settled in your place of work is one that is rarely afforded. Doctors and nurses are trained to look at things with a negative mindset to identify when something will go wrong with a patient. When you combine these two, it would seem that imposter syndrome is the natural consequence of combining our training and the environment in which we are employed. If you identify something you perceive as negative (about yourself), you treat it like a disease. You analyse it, reanalyse it, and then aim to correct it, often by working longer hours and studying harder than you think other people are doing because you believe that those others seem to be doing just fine. All of this occurs at the expense of your mental health.
There will be points within the system when the pressure we put on ourselves will become heavier and heavier. About to step up a level (eg SHO to registrar, registrar to consultant)? At this point, the natural mindset is that at this next level, one must know everything about everything. Sometimes, depending on the people you work with, it can be long before you find out this isn’t true. The honesty and openness with which your seniors approach their relationship with you will either build or shatter this illusion.
Departmental culture is crucial in the development of imposter syndrome. How we treat each other and our work profoundly affects how we value ourselves. Studies involving medical students show that negative interpersonal interactions commonly trigger a shame response. Poor mentorship, pimping (asking a question and then saying, “oh, you should feel shameful because all doctors know that question”) and derogatory talk with supervisors and peers are all common triggers.
The relationship between how you see yourself and how you see your environment also contributes to feelings of shame, self-doubt, and imposter syndrome. People from underrepresented minorities and genders are more likely to feel Imposter syndrome. When people don’t see people who look like themselves, doubt creeps in about where they fit into the system. Seeing your place in the system is easier if people look like you do.
And what is achieved by all of this? A degree of self-doubt is essential in medicine. You have to be open to questions about your motives and methods. When you lose the safety mechanism of open discussion with your colleagues (junior or senior) and the use of the hive mind, arrogance can set in. It becomes only a matter of time before a patient suffers because you did not promote an open atmosphere where anyone could raise their concerns. Someone knew what was wrong with the patient but could not speak up.
There are also times when this self-doubt becomes too much. The time you spend overworking, overstudying, and failing to recognise the success you achieve will ultimately lead to increased stress, burnout, and decreased job satisfaction and performance over time. If you are working so hard that you’re not performing your job effectively, what was the point of overworking in the first place?
To properly address this, we have to consider what we can do to help ourselves and each other and what institutions can do to improve the culture of self-doubt in the workplace.
Helping Yourself
It is important to recognise your feelings of self-doubt and know that they are common, no matter how they may appear.
Find people around you who you can confide in and who will give you realistic and objective feedback.
Make sure you acknowledge your achievements and focus on these in times of weakness.
Helping Others
Supporting your colleagues is crucial
Educate others about imposter syndrome.
Recognise when others may be going through imposter syndrome.
Celebrate the achievements of colleagues.
The Role of Institutions
Prevention is ultimately better than cure. We need to create an environment where people can discuss their feelings openly and feel no shame. Senior clinicians must be honest with juniors about their struggles with confidence and self-doubt. It’s our job to let junior staff know about the times we have struggled, that they aren’t alone, and that we will support them.
How we support junior colleagues is critically important, too. We need to get rid of old-school practices in juniors and medical students. It’s not uncommon for more introspective junior colleagues to lack confidence. Studies show that by setting them up with many things to do/read/study, you are not helping – you are driving them to poorer job performance and lower job satisfaction. Support them, take your time with them and (poorest done in all of medicine) praise them when they do a good job. Write to their supervisor, write fantastic feedback forms for them, and tell your colleagues, in front of them, about the great things they’ve achieved.
“Pimping” and shame-promoting behaviours should be a thing of the past. Shaming does nothing for their learning and creates a lot of negative mental health issues. We must support colleagues who make errors and stop belittling people for their knowledge base.
It ultimately falls on institutions to change their practices. It should not fall to junior doctors and nurses to become more “resilient”. If an environment is toxic, the environment needs fixing, not the individual. Hospitals and departments need to reflect the makeup of society with people of differing genders, ethnic groups and backgrounds. Ultimately, everyone should feel that they belong.
Dedication
Huw: To Prof Ian Sinha, Prof Lyvonne Tume and Dr Costas Kanaris, three people who never faded in their support for me. Even as my situation grew dark, their encouragement shined bright.
References
Bhama AR, Ritz EM, Anand RJ, Auyang ED, Lipman J, Greenberg JA, Kapadia MR. Imposter Syndrome in Surgical Trainees: Clance Imposter Phenomenon Scale Assessment in General Surgery Residents. Journal of the American College of Surgeons. 2021 Nov 1;233(5):633-8.
Bynum IV WE, Varpio L, Lagoo J, Teunissen PW. ‘I’m unworthy of being in this space’: The origins of shame in medical students. Medical Education. 2021 Feb;55(2):185-97.
Clance PR, Imes SA. The imposter phenomenon in high achieving women: Dynamics and therapeutic intervention. Psychotherapy: Theory, research & practice. 1978;15(3):241.
Freeman J, Peisah C. Imposter syndrome in doctors beyond training: a narrative review. Australasian Psychiatry. 2021 Aug 31:10398562211036121.
Khan M. Imposter syndrome—a particular problem for medical students. BMJ. 2021 Dec 9;375.
Lazarus, Arthur, MBA,C.P.E., D.F.A.A.P.L. (2021). Impact of imposter syndrome on physicians’ practice and leadership development. The Journal of Medical Practice Management : MPM, 37(1), 367-372.
Sakulku J. The impostor phenomenon. The Journal of Behavioural Science. 2011;6(1):75-97.
