Our Coaching columnist looks at why we experience impostor phenomenon, and how we can combat these thoughts and gain confidence at work.
GUEST CONTRIBUTOR
Dr Olivia Donnelly is a consultant clinical psychologist and executive coach, leading a staff psychology team at North Bristol NHS Trust that focuses on supporting healthcare professionals and teams to work well and stay well under pressure. She is also participating in a Royal College of Surgeons of England improvement collaborative supporting surgeons after adverse events. Olivia has a particular interest in practical, values-based approaches to promoting psychological safety within teams and across healthcare organisations, based on the foundation that ‘resilience is between us, not just within us’.
It’s the night before a list. You last did this procedure a few weeks ago and you’ve done several successfully before. You notice yourself feeling restless, anxious that you’re not up to it… someone else would perform this better, quicker. Maybe it’s worth asking someone else to cover? Your colleagues seem to operate with confidence so why are you feeling like this after all this time? Maybe this is a sign that you’re not really cut out for this?
This experience of professional self-doubt, of feeling unworthy to be where we are despite objective evidence to the contrary of and anxiety about being exposed as a fraud was first described as the “imposter phenomenon” in 1978.1 These experiences affect up to 76% of surgeons, across demographic groups, and can be associated with depression, anxiety, burnout, impaired performance, reduced professional satisfaction, and feelings of isolation and shame.2–4 They may be present intermittently, heightened by transitions like returning from extended periods of leave or stepping up a grade, or following a medical error.2 Although commonly referred to as impostor ‘syndrome’,3 it is not recognised in the Diagnostic and Statistical Manual of Mental Disorders, and debate exists around its helpfulness as a label.5
While coaching surgeons, I have heard how feelings of self-doubt and anxiety can manifest when doing their day-to-day job (Box 1). Many will experience one of these thoughts when out of their comfort zones (e.g. doing an on-call shift at a new grade or doing a case independently for the first time). Here, however, the overall sense is a positive one of growth and motivation, and once the skills are learnt or experience is gained, the self-doubt reduces. Self-doubt can become problematic when it is distressing or persistent, and when it affects behaviour and learning (Figure 1).
Figure 1 The spectrum of self-doubt, from the lack of it to a level causing distress or affecting behaviour, development and learning
Box 1 Some examples of quotes from surgeons, from those in core training to consultants, who describe feelings of self-doubt and anxiety including (but not limited to) a sense of impostorism
“I’m already thinking about the M&M while I’m operating”
“I always focus on what I could or should do better, not on what I have achieved”
“I constantly think: ‘Don’t ask me!’”
“I feel like I am the weak link”
“Now that I’m a registrar, I should be able to…”
“Now that I’m a consultant, I should have all the answers”
“I think ‘thank goodness that’s over’ at the end of the day… and then I start worrying about tomorrow”
“I always like to check out what I’m doing with someone else… just in case”
“I have to work harder than other people to be good enough”
“I’m only as good as my last operation”
“I feel threatened by other people’s success”
“I find it hard to accept compliments”
Strategies to compensate for persistent self-doubt and anxiety can include overwork and avoidance (Figure 2).6 Overpreparing, overworking clinically or chasing third-party validation is exhausting and unsustainable, and this can have an impact on life outside work. Avoiding opportunities where we fear that we may ‘fall short’ can inhibit our potential to grow and learn, and compound over time into reduced experience.
Figure 2 Overcompensation and avoidance are two strategies utilised by individuals who feel worried that they are not good enough
Dr Olivia Donnelly is a consultant clinical psychologist and head of staff psychology at North Bristol NHS Trust. She is also currently participating in a Royal College of Surgeons of England improvement collaborative on supporting surgeons after adverse events (SUPPORT).7 I asked her about how surgeons might deal with experiencing imposter syndrome.
LC: Please tell us a bit about your work with surgeons and the impostor phenomenon.
OD: I regularly support surgeons experiencing performance-related anxiety and self-doubt but I’m not sure about describing someone as ‘suffering from impostor syndrome’ unless they themselves find it useful. It implies a personal deficit or pathology, with the emphasis on the individual needing to change, and discounts the pressurised, evaluative, competitive and high-stakes context in which surgeons work. Performance anxiety and fear of failure are very real. Judgement is public and life-changing/life-ending complications happen. It is, however, important to recognise that although ‘better safe than sorry’ is in many ways adaptive, you can have feelings of anxiety and perform well at the same time.
LC: There is some rhetoric that these experiences occur predominantly in women. Is this true or is it a misunderstanding?
OD: While impostor experiences are not constrained by demographics, more female than male surgeons (90% vs 68%)8 identify with them.4,6 In general, groups who have experienced bias, microaggression or discrimination from patients or colleagues are more vulnerable.2,3 It is important to explore why those experiencing sexism, racism, classism or other bias might be less inclined to trust in their accomplishments, and for us all to recognise how improving team and organisational culture can significantly influence coping and confidence in our diverse workforces.
LC: So how can we manage self-doubt and anxiety?
OD: Developing individual self-awareness around triggers and our reactions is key. How we talk to ourselves is important: self-criticism can further heighten the sense of threat and our need to be ‘safe, not sorry’. Reminding ourselves that these are normal reactions to challenging situations can encourage a more compassionate perspective.
Shifting from “I’d like to do this procedure BUT I’m anxious” to “I’d like to do this procedure AND I’m anxious” and differentiating our thoughts from facts can help us continue to make progress towards our goals. Cultivating focused attention, mindfulness and breathing techniques allows us regulate our physiology and focus on the present moment, rather than ruminating about what happened last time or what might happen in the future. Together, these approaches increase our ‘psychological flexibility’ to adapt our response to what is needed or helpful, right now. Like any skill, this takes practice, and support from a psychologist or coach can be useful. Some individual strategies are outlined in Box 2 and in the ‘Experiment’ section below.
Box 2 Some individual-focused strategies
Normalising: Feelings are often normal reactions to challenging situations
Mind your BUTS: Shifting from “I’d like to [do this operation] BUT I’m anxious” to “I’d like to [do this operation] AND I’m anxious”
Self-compassion: Using more encouraging words and a tone that is more likely to soothe than heighten threat
De-fusion: Creating some psychological distance between us and our thoughts (see the ‘Experiment’ section)
Perspective taking: What would I say to a good friend? Or a colleague I want to support? What experiences have I had of feeling anxious AND performing well? Who do I value/admire who has performed less-than-perfectly? What strengths do I bring to the team?
Framing: Can I see this anxiety as a sign that I am growing? That I’m stepping out of my comfort zone but not my safety zone?
Focusing on the present: Slow outbreaths or box breathing10 help to bring our mind and body back to the here and now
Noticing assumptions/comparisons: Am I ‘comparing my insides with other people’s outsides’?
Staying connected with other things you value so you are not defined by your job (e.g. time with family, sport, creativity)
Our team context is also significant: ‘Resilience is between, not just within us.’ Performance anxiety and self-doubt feel isolating but are experienced almost universally at some point by surgeons. Colleagues, especially senior ones, sharing their own experiences (e.g. in a departmental ‘gaffe of the week’ or through mentoring) can help normalise doubts, encourage sharing, learning and support, and foster a climate of psychological safety. It is helpful to understand that many successful people have moments of self-doubt but still continue with the task at hand, and may even consider these experiences a sign that they’re challenging themselves and progressing. Some team strategies are suggested in Box 3.
Box 3 Some team-focused strategies
Forums to share complications and errors
Exploring strengths and doubts with supervisors in new rotations
Role modelling from senior leads on experiencing self-doubt and performance anxiety as well as what has helped – being a coach, not a critic
Asking for specific feedback on what you are doing well and areas for growth
Celebrating team successes in clinical meetings
Promoting inclusion and psychological safety in safety briefings and debriefs
Routinely checking in with colleagues after an adverse event
Enhanced support for transitions such as returning to work after parental leave)
EXPERIMENT
Try ‘de-fusing’ your thoughts from fact. The exercise in Figure 3, derived from acceptance and commitment training,9 helps create psychological space between you and your understandable (albeit unhelpful) thoughts and feelings so that you can do what matters.
Figure 3 De-fusion of thoughts and facts: creating psychological space so that we can do what matters
REFLECTION
What are your strengths and attributes? You are more than your job. Your job is an expression of your strengths, choices and hard work, and you are intrinsically worthy of love and respect. What are your strengths? What do people come to you for? Remember that this is generally because of who you are rather than because of what you’ve achieved. Ask five people you trust what they value about you and why.
A thought to leave you with…
“Between stimulus and response there is a space. In that space is our power to choose our response. In our response lies our growth and our freedom.”
This article reflects the opinions of the author(s) and should not be taken to represent the policy and views of the Royal College of Surgeons of England.
References
1.
Clance PR, Imes SA. The imposter phenomenon in high achieving women: dynamics and therapeutic intervention. Psychother Theory Res Pract 1978; 15: 241–247.
Bravata DM, Madhusudhan DK, Boroff M, Cokley KO. Commentary: Prevalence, predictors, and treatment of imposter syndrome: a systematic review. J Ment Health Clin Psychol 2020; 4: 12–16.
Medline A, Grissom H, Guissé NF et al. From self-efficacy to imposter syndrome: the intrapersonal traits of surgeons. J Am Acad Orthop Surg Glob Res Rev 2022; 6: e22.00051.
Noskeau R, Santos A, Wang W. Connecting the dots between mindset and impostor phenomenon, via fear of failure and goal orientation, in working adults. Front Psychol 2021; 12: 588438.
Bolderston H, Greville-Harris M, Thomas K et al. Resilience and surgeons: train the individual or change the system? Bull R Coll Surg Engl 2020; 102: 244–247.
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