"Rising to the Level of Your Incompetence": What Physicians' Self-Assessment of Their Performance Reveals About the Imposter Syndrome in Medicine

Small-Group Discussion Sessions on Imposter Syndrome

INTRODUCTION

The Accreditation Council for Graduate Medical Education requires residency programs to support residents' well-being via established policies and programs. Imposter syndrome has been linked to burnout in residents, and understanding how to combat it may help improve resiliency in residents.

METHODS

We held a facilitator-guided, interactive discussion session for internal medicine residents on the topic of imposter syndrome as part of a larger series of discussion sessions on resident wellness. We repeated the session to capture a different group of residents. A psychologist or chief resident led each 30- to 45-minute session with the option to include an attending physician. Residents, faculty, and a clinical psychologist developed instructions for leading this session. At the end of each session, the facilitator provided attendees with a handout with take-home points and an optional postsurvey to assess learning objectives and ask whether they felt this was an effective intervention to promote resident wellness.

RESULTS

We collected data from 21 residents who attended the small-group discussion sessions. Ninety-six percent of residents felt comfortable recognizing imposter syndrome in themselves, and 62% knew the appropriate next steps after identifying imposter syndrome. Eighty-one percent of residents felt that the imposter syndrome wellness session was an effective intervention to promote resident wellness.

DISCUSSION

Imposter syndrome has been linked to resident burnout, and discussing imposter syndrome was viewed as an effective intervention to promote resident wellness and resiliency. When creating wellness interventions, other programs should consider addressing imposter syndrome.

Role of Technology in Self-Assessment and Feedback Among Hospitalist Physicians: Semistructured Interviews and Thematic Analysis

Background

Lifelong learning is embedded in the culture of medicine, but there are limited tools currently available for many clinicians, including hospitalists, to help improve their own practice. Although there are requirements for continuing medical education, resources for learning new clinical guidelines, and developing fields aimed at facilitating peer-to-peer feedback, there is a gap in the availability of tools that enable clinicians to learn based on their own patients and clinical decisions.

Objective

The aim of this study was to explore the technologies or modifications to existing systems that could be used to benefit hospitalist physicians in pursuing self-assessment and improvement by understanding physicians’ current practices and their reactions to proposed possibilities.

Methods

Semistructured interviews were conducted in two separate stages with analysis performed after each stage. In the first stage, interviews (N=12) were conducted to understand the ways in which hospitalist physicians are currently gathering feedback and assessing their practice. A thematic analysis of these interviews informed the prototype used to elicit responses in the second stage.

Results

Clinicians actively look for feedback that they can apply to their practice, with the majority of the feedback obtained through self-assessment. The following three themes surrounding this aspect were identified in the first round of semistructured interviews: collaboration, self-reliance, and uncertainty, each with three related subthemes. Using a wireframe, the second round of interviews led to identifying the features that are currently challenging to use or could be made available with technology.

Conclusions

Based on each theme and subtheme, we provide targeted recommendations for use by relevant stakeholders such as institutions, clinicians, and technologists. Most hospitalist self-assessments occur on a rolling basis, specifically using data in electronic medical records as their primary source. Specific objective data points or subjective patient relationships lead clinicians to review their patient cases and to assess their own performance. However, current systems are not built for these analyses or for clinicians to perform self-assessment, making this a burdensome and incomplete process. Building a platform that focuses on providing and curating the information used for self-assessment could help physicians make more accurately informed changes to their own clinical practice and decision-making.

Perfectionism, impostor phenomenon, and mental health in medicine: a literature review

OBJECTIVES

The aims of this review, focused on medical students, residents, and physicians, were a) to determine the levels of perfectionism and prevalence of impostor phenomenon, b) to assess the relationship between perfectionism, impostor phenomenon, and mental health, and c) explore how medical culture may influence these personality characteristics.

METHODS

A narrative literature review was conducted. Search terms were entered into PubMed, PsychINFO, Web of Science, EMBASE, and Google Scholar without date or geographic restrictions. The McMaster Critical Review Forms for Quantitative and Qualitative Studies were used for article appraisal. Final decisions on inclusion and exclusion were reached through discussion. Sixteen articles were included in this review and summarized in a data extraction table.

RESULTS

Medical students had similar perfectionism scores to other student groups but scored lower in maladaptive perfectionism. The overall prevalence of the impostor phenomenon ranged from 22.5% to 46.6%. More females (41% - 52%) experienced clinical levels of impostor phenomenon compared to males (23.7% - 48%). Most studies did not find an association between the impostor phenomenon and academic year of training. Both personality characteristics were associated with negative mental health effects. Medical culture can train for and/or exacerbate these characteristics, affecting professional identity formation. Both characteristics contribute to distress for learners during commonly-used teaching methods in medical education.

CONCLUSIONS

Comprehensive changes in medical education that consider the relationship between medical culture, professional identity formation, impostor phenomenon, and perfectionism are needed. Longitudinal studies will help identify the implications of these findings for professional identity formation and medical education.

Veterinarians and impostor syndrome: an exploratory study

BACKGROUND

Impostor syndrome (IS) is the tendency to doubt one's abilities despite positive evidence to the contrary. Individuals with IS are afraid of being discovered as intellectual frauds and attribute their successes to external qualities.

METHODS

An international study explored the prevalence and severity of IS in practicing veterinarians. An anonymous survey consisting of the 20-question Clance Impostor Phenomenon Scale, plus additional demographic and work-related questions, was distributed online.

RESULTS

A total of 941 practicing veterinarians responded. Overall, 631 participants (68 per cent) met or exceeded the clinical cut-off score for IS. Ordinal regressions found that residing in New Zealand (NZ) or the UK, being female or having been in practice for less than five years increased the odds of having a high IS score. The effect of these factors on the perceived degree of impact of IS on participants' professional and personal life was also explored. Women, UK residents and new practitioners reported higher levels of impact in their professional life. However, sex and country of residence did not affect the degree of impact on participants' personal life.

CONCLUSION

Veterinarians in general have an alarmingly high prevalence of IS with young, female graduates practising in the UK and NZ at increased risk.

Impostorism in American medical students during early clinical training: gender differences and intercorrelating factors

OBJECTIVES

This study examined the incidence and severity of impostorism in third-year medical students as they transitioned from the preclinical to clinical phases of training.

METHODS

A cross-sectional study was conducted in third-year medical students (N=215).  Respondents completed a voluntary, anonymous, 60-item survey that included the Clance Impostor Phenomenon Scale and the Perceived Stress Scale.  Student's-t, Mann-Whitney, and Chi-Square tests and Pearson correlation were used to determine differences between subgroups of students and relationships between instruments scores and demographic parameters.

RESULTS

Fifty-nine percent of students responded with N=112 (59% female) completing at least one instrument. The mean impostor score was 63.0 ± 14.6 (moderate-to-frequent impostor feelings) and was 9% higher in females (U=1181, p = .046). Perceived Stress scores for females were 17% higher than males (t₍₁₀₉₎=2.87, p=.005).  Females had lower United States Medical Licensing Examination (USMLE) Step 1 scores (t₍₁₀₇₎= 3.06,  p=.003).  Impostor and perceived stress scores were correlated for males (r₍₄₆₎=.47, p=.002) and females (r₍₆₄₎=.54,p<.0001). Impostor and USMLE Step 1 scores were negatively correlated for males (r₍₄₅₎ =-.32, p= .034) but not females (r₍₆₃₎ = -.11, p=.40).

CONCLUSIONS

 These findings demonstrate the intercorrelation between impostorism and stress in male and female medical students and raise interesting questions regarding the contributions of gender and other factors involved with medical training.

Impostorism in third-year medical students: an item analysis using the Clance impostor phenomenon scale

INTRODUCTION

Impostorism, feelings of distrust in one's abilities and accomplishments despite evidence to the contrary, is frequent in medical students and negatively affects student wellness.

METHODS

The aspects of impostorism that were most prevalent in medical students during the transition from the preclinical to clinical phases of their training were assessed using an anonymous, voluntary 60-item survey that included the Clance Impostor Phenomenon Scale (CIPS) and a 2-item burnout assessment administered in October-November 2018. Ratings of individual CIPS items were compared between items for the entire sample and in subpopulations of students. The correlation of individual CIPS items with CIPS total score was also determined.

RESULTS

A total of 127 of 215 (59%) surveyed students responded, with 112 completing the CIPS with mean score of 63.0 ± 14.6 (moderate-to-frequent impostor feelings). Ratings of individual CIPS items differed significantly between items. Responses also differed depending on gender and perceived burnout or depersonalization.

DISCUSSION

Third-year medical students identified most strongly with items related to unfounded fear of failure, hesitance to share recognition before it is announced, remembering failures rather than successes, believing themselves less capable than others, and worrying about succeeding. In contrast, attribution of accomplishments to luck was not prominent for these students. Responses to certain items also differed depending on gender and perceived burnout or depersonalization, but not self-reported under-represented minority status. This observation may inform the development of interventions tailored to foster wellness as students negotiate the transition from the preclinical to clinical phases of their training.

Prevalence, Predictors, and Treatment of Impostor Syndrome: a Systematic Review

BACKGROUND

Impostor syndrome is increasingly presented in the media and lay literature as a key behavioral health condition impairing professional performance and contributing to burnout. However, there is no published review of the evidence to guide the diagnosis or treatment of patients presenting with impostor syndrome.

PURPOSE

To evaluate the evidence on the prevalence, predictors, comorbidities, and treatment of impostor syndrome.

DATA SOURCES

Medline, Embase, and PsycINFO (January 1966 to May 2018) and bibliographies of retrieved articles.

STUDY SELECTION

English-language reports of evaluations of the prevalence, predictors, comorbidities, or treatment of impostor syndrome.

DATA EXTRACTION

Two independent investigators extracted data on study variables (e.g., study methodology, treatments provided); participant variables (e.g., demographics, professional setting); diagnostic tools used, outcome variables (e.g., workplace performance, reductions in comorbid conditions); and pre-defined quality variables (e.g., human subjects approval, response rates reported).

DATA SYNTHESIS

In total, 62 studies of 14,161 participants met the inclusion criteria (half were published in the past 6 years). Prevalence rates of impostor syndrome varied widely from 9 to 82% largely depending on the screening tool and cutoff used to assess symptoms and were particularly high among ethnic minority groups. Impostor syndrome was common among both men and women and across a range of age groups (adolescents to late-stage professionals). Impostor syndrome is often comorbid with depression and anxiety and is associated with impaired job performance, job satisfaction, and burnout among various employee populations including clinicians. No published studies evaluated treatments for this condition.

LIMITATIONS

Studies were heterogeneous; publication bias may be present.

CONCLUSIONS

Clinicians and employers should be mindful of the prevalence of impostor syndrome among professional populations and take steps to assess for impostor feelings and common comorbidities. Future research should include evaluations of treatments to mitigate impostor symptoms and its common comorbidities.

Prevalence of impostor phenomenon and assessment of well-being in pharmacy residents

Purpose

The purpose of this study was to quantify the prevalence of impostor phenomenon (IP) and to assess well-being in pharmacy residents, as well as analyze the effects of demographics on these outcomes.

Methods

A cross-sectional, survey-based study was performed. Pharmacy residency program directors and pharmacy directors were asked to forward an invitation email to actively enrolled postgraduate year 1 (PGY1) and postgraduate year 2 pharmacy residents in March 2019. The survey used the Clance Impostor Phenomenon Scale (CIPS) to identify IP and the Mayo Clinic Resident/Fellow Well-Being Index (RWBI) to assess resident well-being.

Results

Survey respondents were mostly female, enrolled in PGY1 programs and single with no children. Of the 720 responses included in the study, 57.5% (n = 414) were identified as “impostors” (CIPS score of ≥62), with a mean CIPS score of 64.0 (SD, 15.0). Prior mental health treatment and increased hours worked per week were significant predictors of IP. The greatest correlation was found in those working greater than 80 hours per week compared to less than 60 hours per week (ß = 9.845; P &lt; 0.001). The mean RWBI score was 4.2 (SD, 1.8), with 47.8% (n = 344) of residents scoring ≥5, the cutoff for identifying those at greatest risk of distress. Age, previous mental health treatment, and increasing hours worked per week were significant predictors of RWBI ≥5. CIPS and RWBI scores were found to exhibit weak but significant correlation (ρ = 0.357; P &lt; 0.001).

Conclusion

Pharmacy residents displayed significantly higher prevalence of IP vs comparable groups as well as significantly more distress with potential for a personal and/or professional consequence.

Beyond burnout: looking deeply into physician distress

Physician wellness is an important issue and a growing concern within the medical profession. Although "burnout" is a commonly used term to describe physician distress, it fails to capture the many aspects of medicine that negatively impact physician wellness and what physicians experience. In this article, I will explore the personal (unhealthy perfectionism, pathologic altruism, self-recrimination, and the pitfalls of success), interpersonal (empathic distress, moral suffering, bullying, and marginalization), and systemic (medical culture, workplace environment and burnout, and health care system) factors that act interdependently and synergistically to give rise to physician distress. This article is a call for an earnest discussion and for implementing changes by addressing and reconsidering the place of physician wellness in medical practice, education, and research on the one hand, and its impact on patients, families, and society on the other.

Burnout and imposter syndrome among Saudi young adults. The strings in the puppet show of psychological morbidity

OBJECTIVES

To determine the prevalence of imposter syndrome (IS) among Saudi adults and its association with burnout.

METHODS

Using non-probability convenience sampling, we carried out a cross-sectional analytical study among adults in Northern Saudi Arabia. Data collection toll was a self-administered questionnaire containing young imposter scale (YIS), Maslach burnout inventory (MBI) and depression, anxiety, and stress scale 21 (DASS 21). These 3 scales are valid and reliable measurement tools for measuring IS, burnout, and psychological morbidity.

RESULTS

In the study sample (n=384), imposterism was present among 222 adults (57.8%). Moderate and severe symptoms of depression were present in 217 (56.5%), symptoms of stress in 210 (54.7%), and symptoms of anxiety in 126 (32.8%). Burnout was measured in 3 domains of depersonalization, emotion exhaustion, and personal accomplishments. High degree of depersonalization was found in 221 (57.6%), higher emotional exhaustion in 246 (64.1%) while lower personal accomplishment was present in 126 (32.8%). We found statistical association between IS and gender (p less than 0.01), depression (p less than 0.001) stress (p less than 0.001) and all 3 domains of burnout (p less than 0.01). Imposter syndrome was not found associated with anxiety (p=0.97). Young imposter scale score was associated with all the 3 domains of burnout even after controlling for depression, anxiety, and stress.

CONCLUSION

Imposter syndrome is frequent among Saudi adults and associated with all 3 burnout domains. Mental health domains like burnout, depression, stress, and anxiety were found associated with IS.

Time for change: Overcoming perpetual feelings of inadequacy and silenced struggles in medicine

Focusing on support of psychological wellness in medical students, residents and physicians, this commentary highlights the need for cultural change and the accompanying importance of leadership.

Impostor syndrome among physicians and physicians in training: A scoping review

CONTEXT

Impostor syndrome (IS) is increasingly recognised as a condition among physicians and physicians in training. Impostor syndrome is especially problematic because of its association with increased rates of burnout and suicide. In order to address this issue, we need to fully understand its prevalence, scope, and factors associated with IS. The purpose of this scoping review is to analyse the existing literature on IS among practising physicians and physicians in training in order to identify current trends and directions for future research.

METHODS

The authors conducted a literature search of nine databases for any articles on IS among practising physicians or physicians in training published prior to January 2019. Two reviewers independently screened articles and identified 18 papers meeting the study inclusion criteria. Two authors independently extracted data and performed quantitative and qualitative syntheses consistent with best practice recommendations for scoping reviews.

RESULTS

Most studies utilised the Clance Impostor Phenomenon Scale and cited rates of IS ranging from 22% to 60%. Studies found that gender, low self-esteem and institutional culture were associated with higher rates of IS, whereas social support, validation of success, positive affirmation, and both personal and shared reflections were protective. Overall, IS was also associated with higher rates of burnout.

CONCLUSIONS

This review summarises the existing literature on IS among practising physicians and physicians in training, providing valuable insights and areas for future research.

Releasing the Net to Promote Minority Faculty Success in Academic Medicine

Underrepresented minority faculty in academic medicine continue to be underrepresented in academic health centers across the country. Their underrepresentation impacts advancements in clinical care, education, and discovery and slows our forward progress in the field. Underrepresented in medicine faculty includes people who are black or African American, Hispanic or Latinx, or Native American. Barriers to underrepresented faculty recruitment, retention, and advancement include minority and gratitude taxes, imposter syndrome, and a lack of an appreciation of power distance and distance traveled. This article reviews five barriers to progress in achieving appropriate diversity among faculty and leadership of academic health centers, focusing on the multiplying effects of these barriers and potential steps forward.

Inequity and Women Physicians: Time to Change Millennia of Societal Beliefs

Gender inequities date back thousands of years, with women expected to be caregivers at home and men expected to be leaders with occupations outside the home. In more recent history, women have trained in various professions, including medicine. Although the number of female physicians has risen consistently over the past several decades and half of US medical students now are women, gender inequities persist and are due, at least in part, to implicit (unconscious) biases held by doctors, other health care professionals, and patients and their families. Implicit biases negatively affect women in their medical careers and contribute to slower advancement, less favorable evaluations, underrepresentation in leadership positions, fewer invited lectures, lower salaries, impostor syndrome, and burnout. Despite efforts to address gender biases, studies in academic medical centers indicate no major change over a 20-year span. Management of implicit gender bias at the organizational level is imperative. Strategies include implicit bias training for doctors and other staff; development of a transparent and equitable compensation plan; and transparent processes for promotion and hiring, mentorship, and sponsorship of women physicians for grand rounds, lectureships, committees, leadership positions, and awards. Achievement of equity for women physicians requires effort and ultimately a culture change. Gender equity in the medical profession will lead to improved physician wellness, retention of women physicians, and improved access to and quality of health care.

The Inner Lives of Doctors: Physician Emotion in the Care of the Seriously Ill

Elisabeth Kübler-Ross' seminal 1969 work, On Death and Dying, opened the door to understanding individuals' emotional experiences with serious illness and dying. Patient's emotions, however, are only half the story in the patient-physician relationship. In recent years physicians' emotional reactions have gotten more attention. These sometimes-unacknowledged emotions influence how we approach our work, including life and death decisions. This article reviews some of the main emotions physicians experience when caring for seriously ill and dying patients and the challenges physicians face in regulating their emotions in a professional setting. We also discuss some of the ways that physician emotion may influence medical decision-making and contribute to conflict. Attention to the emotional level of physician experience may promote better care.

Neurodevelopmental-behavioural paediatrics

PURPOSE OF REVIEW

Neurodevelopmental-behavioural paediatrics (NBP) is a field of medical practice that has arisen in response to recent changes in child health epidemiology. This review considers how the profession of NBP is addressing clinical need, and discusses possibilities for future development of the field.

RECENT FINDINGS

Research publications relevant to NBP clinical practice focus primarily on cause (e.g. biology, imaging, neuropsychology), early detection, diagnostic methodologies and initial treatment strategies, with emphasis on psychotropic medication. Translation of this research implies that NBP clinical services should be undertaken using algorithmic methodologies, and evaluated against treatment attributable outcomes. These strategies and outcomes potentially define the central purpose of the profession; however, they may not be sufficient to best help the children seen.

SUMMARY

Two sets of information inform and extend consideration of NBP purpose and strategy. Firstly, longitudinal and adult studies indicate that even with treatment, problems persist in adult life for a significant proportion of children with neurodevelopmental-behavioural disorders. Secondly, NBP clinical practice deals with significant, irreducible complexity and uncertainty, arising from both child-diagnostic and contextual factors. Complexity limits the extent to which evidence-based clinical algorithms are able to inform care. Suggestions for how to address both challenges are offered.

Burnout and attrition: Expanding the gender gap in neurology?

Neurology faces an increasing shortage of neurologists in the United States due to a growing demand for neurologic services. A 7% increase in the supply of neurologists is predicted from 2012 to 2025, whereas the demand will rise by 16%. An increase in the neurology workforce is critical to meet the demands, and a significant gender gap remains within the workforce that must be addressed to further ease the discrepancy between supply and demand. Individual, institutional, and societal factors contribute to this gender discrepancy and potentially result in the burnout or soft attrition of women from neurology. These factors, including earning disparity between male and female neurologists, one of the largest gaps in pay for any medical specialty, and the lack of representation at higher academic levels with only 12% (14 of 113) of neurology department chairs at academic medical centers being women, could lead to increased attrition of women from neurology. Identifying and mitigating these factors may help narrow the gender gap and increase the supply of neurologists to better meet future demand.

Attitudes Towards Physicians Requiring Remediation: One-of-Us or Not-Like-Us?

PURPOSE

The data for this paper were collected as part of a larger project exploring how the medical profession conceptualizes the task of supporting physicians struggling with clinical competency issues. In this paper, the authors focus on a topic that has been absent in the literature thus far-how physicians requiring remediation are perceived by those responsible for organizing remediation and by their peers in general.

METHOD

Using a constructivist grounded theory approach, the authors conducted semistructured interviews with 17 remediation stakeholders across Canada. Given that in Canada health is a provincial responsibility, the authors purposively sampled stakeholders from across provincial and language borders and across the full range of organizations that could be considered as participating in the remediation of practicing physicians.

RESULTS

Interviewees expressed mixed, sometimes contradictory, emotions toward and perceptions of physicians requiring remediation. They also noted that their colleagues, including physicians in training, were not always sympathetic to their struggling peers.

CONCLUSIONS

The medical profession's attitude toward those who struggle with clinical competency-as individuals and as a whole-is ambivalent at best. This ambivalence grows out of psychological and cultural factors and may be an undiscussed factor in the profession's struggle to deal adequately with underperforming members. To contend with the challenge of remediating practicing physicians, the profession needs to address this ambivalence and its underlying causes.

Exploring medical leader identity and its formation

PURPOSE

"Becoming" a doctor involves the acquisition of medical knowledge, skills and professional identity. Medical professional identity formation (MPIF) is complex, multi-factorial and closely linked to societal expectations, personal and social identity. Increasingly, doctors are required to engage in leadership/management involving significant identity shift. This paper aims to explore medical professional identity (MPI) and MPIF in relation to doctors as leaders. Selected identity theories are used to enrich the understanding of challenges facing doctors in leadership situations and two concepts are introduced: medical leader identity (MLI) and medical leader identity formation (MLIF) and consideration given to how they can be nurtured within medical practice.

DESIGN/METHODOLOGY/APPROACH

A rapid conceptual review of relevant literature was carried out to identify a set of relevant concepts and theories that could be used to develop a new conceptual framework for MLI and MLIF.

FINDINGS

MLIF is crucial for doctors to develop as medical leaders, and, like MPIF, the process begins before medical school with both identities influenced, shaped and challenged throughout doctors' careers. Individuals require support in developing awareness that their identities are multiple, nested, interconnected and change over time.

ORIGINALITY/VALUE

This paper draws on concepts from wider literature on professional identity, in relation to how doctors might develop their MLI alongside their MPI. It offers a new perspective on MPI in the light of calls on doctors to "become and be healthcare leaders" and introduces the new concepts of MLI and MLIF.

Exploring and Managing the Impostor Phenomenon in Palliative Care: A Case Series

The impostor phenomenon (IP) describes the experience of questioning one's abilities and fearing exposure as an intellectual fraud, despite objective evidence of success. The IP has been identified in high-achieving professionals across a variety of disciplines, including clinical medicine, and can be associated with significant anxiety and psychological distress. In this series, we present three authentic cases that demonstrate how the IP may manifest in palliative care practice. Acknowledging the current emphasis on clinician wellness and burnout, we suggest that the IP may be one important source of distress for many early-career clinicians in palliative care. With the physician as the focus of each case, we explore the difficult emotions faced and highlight how palliative care clinicians may be uniquely vulnerable to the IP. We then identify concrete strategies to help clinicians manage feelings of IP and enhance their professional well-being.

How Medical Error Shapes Physicians' Perceptions of Learning: An Exploratory Study

PURPOSE

Error is inevitable in medicine, given its inherent uncertainty and complexity. Errors can teach powerful lessons; however, because of physicians' self-imposed silence and the intricacies of responsibility and blame, learning from medical error has been underexplored. The purpose of this study was to understand how physicians perceived learning from medical errors by exploring the tension between responsibility and blame and factors that affected physicians' learning.

METHOD

Nineteen physicians participated in semistructured interviews, conducted in 2016-2017 at Western University in Canada, that probed their experiences in learning from medical errors. Data collection and analysis were conducted iteratively, with themes identified through constant comparative analysis.

RESULTS

Participants felt personal responsibility and blame for their errors. Residency produced particularly salient memories of errors. Participants identified interconnecting cultural factors (normalizing error, peer support and mentorship, formal rounds) and individual factors (emotional response, confidence and experience), which either helped or hindered their perceived learning.

CONCLUSIONS

Learning from medical error requires navigation through blame and responsibility. The keen responsibility felt by physicians must be acknowledged when enacting a system-based approach to medical error. Adopting a learning culture perspective suggests opportunities to enable and disable features of the learning environment to optimize learning from error as residents learn to become the most responsible physician for all outcomes. A better understanding of the factors that shape learning from error can help make the transition from error to learning more explicit, thereby increasing the opportunity to learn and teach from errors that permeate the practice of medicine.

Factors That Influence the Choice of Academic Pediatrics by Underrepresented Minorities

OBJECTIVES

Our objective for this study was to explore the experiences of faculty in academic pediatrics who are underrepresented minorities (URMs) at 2 urban medical centers, in particular, the experiences that influenced their pursuit of academic pediatrics.

METHODS

Three focus groups were conducted in 2016 with URM faculty from Howard University College of Medicine and Children's National Health System to explore how they were influenced to pursue academic pediatrics. Ten 1-on-1 interviews were also conducted in 2017 with URM faculty at Children's National Health System. Focus groups were coded and analyzed by the research team using standard qualitative methods. The 1-on-1 interviews were coded and analyzed by the primary investigator and verified by members of the research team.

RESULTS

A total of 25 faculty participated in the study (15 in the focus groups and 10 in individual interviews). Eighteen of the faculty were women and 7 were men. Findings revealed that mentorship, family, and community influenced participants' career choices. Barriers for URMs in academic pediatrics included (1) lack of other URMs in leadership positions, (2) few URMs practicing academic pediatrics, and (3) the impact of racism and gender and implicit bias in the medical field.

CONCLUSIONS

Mentorship and family are major influences on why URMs become academic pediatricians. Lack of URMs in leadership positions, racism, gender bias, and implicit bias are barriers for URMs in academic pediatrics. More research should be conducted on ways to enhance the experience of URMs and to reduce barriers in academia.

Power and physician leadership

Power and leadership are intimately related. While physician leadership is widely discussed in healthcare, power has received less attention. Formal organisational leadership by physicians is increasingly common even though the evidence for the effectiveness of physician leadership is still evolving. There is an expectation of leadership by all physicians for resource stewardship. The impact of power on interprofessional education and practice needs further study. Power also shapes the profession’s attempts to address physician and learner well-being with its implications for patient care. Unfortunately, the profession is not exempt from inappropriate use of power. These observations led the authors to explore the concept and impact of power in physician leadership. Drawing from a range of conceptualisations including structuralist (French and Raven), feminist (Allen) and poststructuralist (Foucault) conceptualisations of power, we explore how power is acquired and exercised in healthcare systems and enacted in leadership praxis by individual physician leaders (PL). Judicious use of power will benefit from consideration and application of a range of concepts including liminality, power mediation, power distance, inter-related use of power bases, intergroup and shared leadership, inclusive leadership, empowerment, transformational leadership and discourse for meaning-making. Avoiding abuse of power requires moral courage, and those who seek to become accountable leaders may benefit from adaptive reflection. Reframing ‘followers’ as ‘constituents or citizens’ is one way to interrupt discourses and narratives that reinforce traditional power imbalances. Applying these concepts can enhance creativity, cocreation and citizenship-strengthening commitment to improved healthcare. PLs can contribute greatly in this regard to further transform healthcare.

Strengthening Teachers' Professional Identities Through Faculty Development

Although medical schools espouse a commitment to the educational mission, faculty members often struggle to develop and maintain their identities as teachers. Teacher identity is important because it can exert a powerful influence on career choice, academic roles and responsibilities, and professional development opportunities. However, most faculty development initiatives focus on knowledge and skill acquisition rather than the awakening or strengthening of professional identity. The goal of this Perspective is to highlight the importance of faculty members' professional identities as teachers, explore how faculty development programs and activities can support teachers' identities, and describe specific strategies that can be used in professional development. These strategies include the embedding of identity and identity formation into existing offerings by asking questions related to identity, incorporating identity in longitudinal programs, building opportunities for community building and networking, promoting reflection, and capitalizing on mentorship. Stand-alone faculty development activities focusing on teachers' identities can also be helpful, as can a variety of approaches that advocate for organizational change and institutional support. To achieve excellence in teaching and learning, faculty members need to embrace their identities as teachers and be supported in doing so by their institutions and by faculty development.

Impostorism: An evolutionary concept analysis

AIM

The aim of this study was to explore the concept of impostorism as applied to nursing and other disciplines.

BACKGROUND

Impostorism has not been well defined or studied in nursing. Researchers have not studied connections between role transition stress of new graduates and impostorism, despite evidence that nursing students experience impostorism during undergraduate studies.

DESIGN

Rodgers' evolutionary concept analysis was the method used in this study.

DATA SOURCES

The databases used were Academic Search Complete, Cumulative Index to Nursing and Allied Health Literature, Health and Psychosocial Instruments, Health Source: Nursing/Academic Edition, Medical Literature Analysis and Retrieval System Online, PsycARTICLES, Psychology and Behavioral Sciences Collection, PsycINFO, SocINDEX, and Dissertations and Theses databases.

REVIEW METHODS

All nursing-specific citations were included in the literature sample. Of the remaining non-nursing citations, stratified random sampling provided 28 non-nursing citations. An additional purposive sampling of seminal impostorism publications resulted in 46 resources for analysis.

RESULTS

Concept analysis revealed that key attributes of impostorism include fear of failure and difficulty accepting praise. Impostorism antecedents relate to personality, attribution, family, workplace, and sociodemographic variables. According to concept analysis, a conceptual definition emerges of impostorism as a subjective, inaccurate self-assessment involving feelings of intellectual and professional incompetence and fraudulence despite external evidence of success.

CONCLUSION

Impostorism has undergone evolutionary changes in various disciplines. However, the nursing discipline needs more research related to nurses' experiences with impostorism in the workplace.

Tackling the imposter phenomenon to advance women in neurology

Recent literature documents that women comprise an increasing proportion of the neurology workforce but still lag behind male counterparts in publications and promotion. There are many reasons for gender disparities in neurology including family responsibilities, different career goals, lack of mentorship, cultural stereotypes, lack of institutional funding, biases, and professional isolation. Another contributing factor receiving relatively little recognition is the imposter phenomenon. This review highlights recent literature on gender differences in neurology, the definition of the imposter phenomenon, and research on the imposter phenomenon in academic medicine. Approaches for managing the imposter phenomenon are described including personal, mentoring, and institutional strategies. Further research is needed to understand the frequency of the imposter phenomenon at different levels of seniority and optimal strategies for prevention and management.

Shifting and Sharing: Academic Physicians' Strategies for Navigating Underperformance and Failure

PURPOSE

Medical practice is uncertain and complex. Consequently, even outstanding performers will inevitably experience moments of underperformance and failure. Coping relies on insight and resilience. However, how physicians develop and use these skills to navigate struggle remains underexplored. A better understanding may reveal strategies to support both struggling learners and stressed practitioners.

METHOD

In 2015, 28 academic physicians were interviewed about their experiences with underperformance or failure. Constructivist grounded theory informed data collection and analysis.

RESULTS

Participants' experiences with struggle ranged from patient errors and academic failures to frequent, smaller moments of interpersonal conflict and work-life imbalance. To buffer impact, participants sometimes shifted their focus to an aspect of their identity where they felt successful. Additionally, although participants perceived that insight develops by acknowledging and reflecting on error, they sometimes deflected blame for performance gaps. More often, participants seemed to accept personal responsibility while simultaneously sharing accountability for underperformance or failure with external forces. Paradoxically, participants perceived learners who used these strategies as lacking in insight.

CONCLUSIONS

Participants demonstrated the protective and functional value of distributing responsibility for underperformance and failure. Shifting and sharing may be an element of reflection and resilience; recognizing external factors may provide a way to gain perspective and to preserve the self. However, this strategy challenges educators' assumptions that learners who deflect are avoiding personal responsibility. The authors' findings raise questions about what it means to be resilient, and how assumptions about learners' responses to failure may affect strategies to support underperforming learners.

Striving While Accepting: Exploring the Relationship Between Identity and Implicit Bias Recognition and Management

PURPOSE

Implicit biases worsen outcomes for underserved and marginalized populations. Once health professionals are made aware of their implicit biases, a process ensues where they must reconcile this information with their personal and professional identities. The authors sought to explore how identity influences the process of implicit bias recognition and management.

METHOD

Using constructivist grounded theory, the authors recruited 11 faculty and 10 resident participants working at an academic health science center in Canada. Interviews took place from June to October 2017. Participants took an online version of the mental illness implicit association test (IAT) which provides users with their degree of implicit dangerousness bias toward individuals with either physical or mental illness. Once they completed the IAT, participants were invited to draw a rich picture and interviewed about their picture and experience of taking their IAT. Data were analyzed using constant comparative procedures to develop focused codes and work toward the development of a deeper understanding of relationships among themes.

RESULTS

Once implicit biases were brought into conscious awareness, participants acknowledged vulnerabilities which provoked tension between their personal and professional identities. Participants suggested that they reconcile these tensions through a process described as striving for the ideal while accepting the actual. Relationships were central to the process; however, residents and faculty viewed the role of relationships differently.

CONCLUSIONS

Striving for self-improvement while accepting individual shortcomings may provide a model for addressing implicit bias among health professionals, and relational dynamics appear to influence the process of recognizing and managing biases.

Evaluation Apprehension and Impression Management in Clinical Medical Education

Historically, clinical medical education has relied on subjective evaluations of students and residents to judge their clinical competence. The uncertainty associated with these subjective clinical evaluations has produced evaluation apprehension among learners and attempts to manage one's professional persona (impression management) among peers and supervisors. Such behavior has been documented from antiquity through the Middle Ages to the present, including in two new qualitative studies in this issue of Academic Medicine on the social psychology of clinical medical education. New approaches to medical education, including competency-based education, mastery learning, and assessment methods that unite evaluation and education, are slowly changing the culture of clinical medical education. The author of this Invited Commentary argues that this shift will bring greater transparency and accountability to clinical medical education and gradually reduce evaluation apprehension and the impression management motives it produces.