The path to becoming a physician includes may include many accomplishments
— like earning a coveted dermatology residency — but some physicians feel
inadequate despite these successes. Such physicians are often plagued by a common
but under-diagnosed condition called imposter syndrome, in which they feel
that their achievements, services provided, and connections with other physicians
and patients are inadequate. This article offers healthcare professionals tips to
recognize the condition and suggestions for treatment.
Wikipedia describes a psychological phenomenon in which people are unable to internalize their accomplishments. They dismiss their proof of success as luck, timing or their own deceit. Despite external evidence of their competence, they are convinced they are frauds who do not deserve the success they have achieved (1).
Dr. John-Henry Pfifferling, an applied medical anthropologist who specializes in dealing with distressed and burned-out physicians, notes the prevalence among physicians — especially women — of this phenomen, which was called Imposter Syndrome by clinical psychologists Pauline Clance and Suzanne Imes, in their work with female graduate students in 1978 (2). (It is also known as imposter phenomenon or fraud syndrome.) However, he is not convinced it is gender-specific.
Dr. Pfifferling cites the extreme example of a female plastic surgeon referred to his Center for Professional Well Being (CPWB) by the chief of staff of her hospital, where her problematic behavior was jeopardizing her hospital privileges.
“She was sent to us by her Chief of Staff because she was so often dazed, tired and needed to be roused,” Dr. Pfifferling says. “When we took her history, she described feeling an obligation to travel to many different hospitals, to take on extra cases, in an exhausting effort to please both her patients and her referrals. Adding to her distress, she could not vent the anger provoked by the physical and mental pressure she was experiencing because, as a solo practitioner, she had no empathetic colleagues. And when we asked her about time for life, her sadness was palpable.”
Dr. Pfifferling and his partner, Jeanne Wagner, MSW, LCSW, first assessed the client.
“We checked her schedule — particularly how much travel time she spent in rounding at many different hospitals — and asked her if she really needed to go to all those places,” Dr. Pfifferling says. “We gave her tools to correct the problems that brought her to us. We gave her specific things to do: We changed her work schedule, changed places where she traveled, cut back on various things and there were no more complaints.”
While Dr. Pfifferling and Wagner considered their intervention successful when a letter from her chief of staff said that the issues had been satisfactorily resolved, the client ultimately took her own life.
“She had committed surgical suicide by slashing her wrists expertly and cleanly,” explains Dr. Pfifferling, who says he is still haunted by his inability to do more to prevent the tragedy. “We did what we do — I as a coach, teacher and anthropologist and Jeanne as a psychiatric social worker. We knew there was something more deeply wrong but could not get her to share problems, and although we referred her to a psychiatrist, he was fooled by her façade of competence, convinced that her problems were just time management.”
Recognizing the Problem
Dr. Pfifferling emphasizes that the case above is an extreme example, although the incidence of the syndrome among physicians is relatively common. Typically, as a result of the dread and fear of being revealed as the frauds they believe they are, he says, they either procrastinate or work harder and longer.
“Their habitual world view is to focus on weaknesses; they are constantly comparing themselves to others and always falling short in the comparison in their own estimation,” Dr. Pfifferling says. “Their most common internal or articulated thoughts are: ‘No matter what I do it’s never enough, or, it’s not good enough or I can never really be successful.’”
This tape plays constantly in their head, and, “as a result of this self-imposed distress, they can’t be in the moment,” Dr. Pfifferling notes, adding, ‘“Success’ has a different reality to them. They don’t react to it normally. They just don’t accept it and validation from the rest of the world is never sufficient for them. Often they feel hopeless—not realizing they are victims of a particular kind of mythic worldview, which has become their reality.”
An Approach to Treatment
Yet, Dr. Pfifferling is quick to assert, those suffering from Impostor Syndrome, as well as other problems including the closely related Internal Judge Syndrome, do want to have more joy in their lives. They do want to demand less of themselves and be less consumed by work, but it requires a conscious effort.
Dr. Pfifferling says the fact that he can give a name to this collection of symptoms is often a relief to physicians, who are accustomed to seeking a diagnosis as a first step in resolving the problem, and then finding a treatment.
“The advantage of a label from a therapeutic or healing perspective is that you can determine whether or not something can be done,” Dr. Pfifferling says.
However, he is quick to assert one thing.
“We do not diagnose, we assess – this is an educational intervention based on organizational development, not psychological treatment,” Pfifferling says. “The free-flowing fear and anxiety are replaced by a label and the knowledge that they are not alone. And if there is in fact a hopeful prognosis and a treatment plan there is relief.” And relief is the name of the game.
“In our case, we look at them and see how demanding they are of themselves and how much trouble they have letting go and learning to be joyful,” he explains. He stresses the importance of teaching them “letting-go skills,” and “the advantages of short, medium and long bouts of joyfulness.” In short, he says, “We give them very specific skills they can use to neutralize the components of the syndrome and they are working towards being less consumed by it.”
Their approach is specific.
“We work on a behavioral intervention model,” Dr. Pfifferling says. “The intervention is short-term but intensive, typically involving 6 to 8 hours sessions over a period of 1 to 3 days after taking a prehistory on the phone.”
History from referral source. First, they gather information from their referral source, who may be a senior partner, someone from the physician well being committee at their hospital or the state medical physician’s health program. A typical ‘presenting problem’ is that the referred physician seems overwhelmed — behind on charts, late on timely response to pages, late or absent for business meetings.
Pre-history on phone. Next comes a discussion of methodology, how the program works. They are asked to bring a significant other (SA), usually a spouse, but it may be a co-worker, nurse or a friend, who will become their first line of support in implementing the plan devised. They also set up a place and time to meet.
History from client. During the meeting, Dr. Pfifferling and/or his CPWB colleague look for facets of perfectionism and self-criticism that may signal the Impostor Syndrome or the closely relation Internal Judge Syndrome. “To help us make the ‘diagnosis,’ we review a checklist with the physicians, who respond with checkmarks on specific items,” Dr. Pfifferling says. (See checklist.) “Usually we discover unrealistic expectations, easily overwhelmed by extra tasks, never caught up, comments they easily make about others being better and lots of worry. Often we will give them a list of fears to see which ones seem to fit. If ‘I will be found out’ comes up as well as ‘over-preparation’ and ‘overwork’ we get a ‘hit.’ Most of our clients present with a significant other (SA), usually the spouse, but sometimes a nurse or office manager, who corroborates their fatigue, worry and discounting praise.”
Assessment. Dr. Pfifferling says they pay particular attention to the narrative from patients, especially when they describe most of the items on the list. “We ask about success and joy and watch their reaction,” he notes. “Success is described as ephemeral and transient, and filled with haunting and dread. Sometimes we will add a copy of a burn-out risk appraisal or even a burnout test (the MBI—Maslach Burnout Inventory).”
Where SA comes in — Dr. Pfifferling says spouses/SAs are regarded as co-counselors who are an important source of feedback to him and support to the client. “Thus, when we explain the syndrome, the spouse is part of the session,” he says. “They also then gain insight and recognition—and learn how they can help or hinder progress.”
Getting Down to Work
The risk appraisal opens up behavior modifiers, specific items they can work on, with the spouse/SA corroborating their fatigue, worry and discounting praise.
“We usually give them realistic and feasible exercises,” Dr. Pfifferling says, such as the following:
Writing out their “assets” — This includes special things they can do or are, using their spouse/SA and their history to affirm such positives.
Mirroring their discounting —When they compulsively discount their ‘assets,’ a partner mirrors their discountings so they become aware of how easily they self discount.
Re-enforcing desirable behavior — This involves inserting a momentary reminder when they do the opposite of their imposter traits, then having them silently whisper ‘good for me.’”
Learning to be more at ease/in the moment — Clients may be asked to keep notes on what transpired right after they’ve taken an action that would typically trigger the harmful habits, such as self criticism and obsession, and are sometimes given “anchors” attached to sounds or visuals to keep them in the moment instead.
Scheduled “ease time” — At these times, clients are urged to listen to music or whatever that is ease-producing, trying to focus on their uniqueness and avoiding comparison with others.
Letting go — This exercise involves having the client first notice, then practice letting go of harmful attitudes and fears. Dr. Pfifferling says these behavioral modifiers can be tailored to the individual’s receptivity and willingness to neutralize the habits. “We do not fight the Syndrome, but recognize that at some past point these behaviors were ‘useful,’” Dr. Pfifferling says.
A follow-up plan is designed either in person or by phone when clients — some of whom are self-referred — report “relief” or when they and their referral supervisor report no more problems.
“We are not looking for perfection but that the people have more joy, are less self-demanding, and more ease,” Dr. Pfifferling says. “So, for example, when they can get up in a weekend without a long, long to-do list, and they are pleased with doing some of the items, and report no guilt about the unfinished ones, we celebrate. That is, we ask them to celebrate. At the practice level, when they no longer compulsively look at numbers of procedures, patients seen, over-booked calendars comparing themselves to their colleagues, we are pleased.”
Follow-up involves efforts to maintain the progress made.
“When these physicians are referred, we share and modify a monitoring form (Positive Professionalism) with the physician and the referring person,” Dr. Pfifferling says.
“We are convinced that the Imposter Syndrome is almost an epidemic among physicians but it is a silent epidemic,” Dr. Pfifferling says. “It usually presents to us as a part of burnout (emotional exhaustion) or even more commonly as acting out (“disruptive”) behavior.”
He says the key to their work is promoting an understanding of realistic and unrealistic expectations.
“With our help, they can learn to establish boundaries, to let others help care for their patients, to know that it’s ok to say ‘no’ without fear of angering or disappointing others,” Dr. Pfifferling says. “Our challenge is to help them see the problem as a mythical dilemma—their reality is not real but an adaptive response, no longer useful but easily justified. Our objective is to help them work toward, relief, transformation, letting go so we can both care for their patients and enjoy their lives.”
SIDEBAR: Recognize the Signs
Those “suffering” from Impostor Syndrome have valid, tangible accomplishments, yet they are plagued by the fear that they cannot repeat them or that they are somehow not as capable or as bright as others.
• They expect to do things flawlessly and with ease.
• They often they feel overwhelmed and like a “failure.”
• They overrate other’s strengths—always believing that they themselves come up short.
• They worry excessively and have recurrent self-doubts.
• They are terrified of making mistakes and feel dread at the prospect and humiliation when do make mistakes.
• When needing to perform they often experience anxiety, worry and fear, and they expand enormous energy covering up their fear.
• They are so worried they won’t be able to do well that they may procrastinate and sometimes experience paralysis.
• At other times they overwork and over-prepare, robbing themselves of time that could be better spent.
• They are ingenious in denying their competency or great at discounting praise.
• As a result of their underlying fear of success, they feel guilty if they seem successful and worry that more and unreasonable demands will be placed on them.
SIDEBAR: Imposter Syndrome Quiz
_ I avoid evaluations, if at all possible, and dread others evaluating me.
_ When people praise me for something I have accomplished, I’m afraid I won’t be able to live up to their expectations in the future.
_ I’m often afraid that others will discover how much knowledge or skills I really lack.
_ I’m often afraid that I may fail at a new task or skill even though I generally do well at what I attempt.
_ I have “succeeded” on a test even though I was afraid that I would not do well before I took it?
_ I can give the impression that I am more competent than I really am?
_ I often think I gained my present position because I happened to be in the right place at the right time or knew the right people.
_ I’m afraid people important to me may find out that I’m not as capable as they think I am.
_ I almost always remember incidents in which I have not done my best—more than those when I have done my best or done well.
_ I rarely do a case or project as well as I would have liked to.
_ I often believe that my success in my life has been the result of some kind of error.
_ Often, I feel my “success” has been due to some kind of luck.
_ It’s very hard for me to accept compliments or praise about my success, intelligence or accomplishments.
_ I almost always feel disappointed in my present (and past) accomplishments, and think I should have accomplished much more.
_ When I succeed at something (and receive some recognition) I have doubts that I can repeat such success. (Success to me usually means I need recognition.)
_ When I receive praise for something I have accomplished I tend to almost always discount the importance of what I have done.
_ I commonly compare my ability to those around me and think they are more skilled, or intelligent, or efficient than I am.
_ I usually worry about not succeeding with a case or project (or exam) though others around me have confidence that I will do well.
_ If there is a real possibility I will receive a promotion, or receive recognition, I hesitate to tell others until it is an accomplished fact.
_ I feel bad and discouraged if I’m not the best or at least very special in situations that involve achievement.
If you have seven or more, you suffer from Imposter Syndrome.