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Our study confirms occurrence of imposter phenomenon in radiologists
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There is a statistical correlation between imposter phenomenon and burnout
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A pilot workshop utilizing medical improv techniques to address imposter phenomenon was well received.
Abstract
Purpose
Imposter phenomenon refers to feelings of inadequacy due to inability to internalize evident success. While high achievers such as physicians have been known to exhibit imposter phenomenon, there is limited literature specific to radiologists. Our purpose was to (1) investigate imposter phenomenon in radiologists and assess correlation with burnout, and (2) pilot an intervention aimed at addressing imposter phenomenon through improvisational theater techniques.
Methods
Part 1 - Clinical radiology faculty at a single large academic medical center completed an anonymous survey with questions related to demographics, burnout (derived from the validated Mini-Z assessment tool), and imposter phenomenon. Part 2 - A one-hour interactive workshop on imposter phenomenon was organized for the radiology department at the same institution. The workshop included the Clance Imposter Phenomenon Scale (CIPS). A post-workshop survey rating was also performed.
Results
Part 1 - Of 30 clinical radiology faculty who participated in the survey, 83% reported feelings of imposter phenomenon during their career. There was significant (p = 0.024) correlation between imposter phenomenon and burnout. Part 2 - Of 21 members of the Department of Radiology who completed the CIPS in the interactive workshop, 71% exhibited frequent or intense symptoms of imposter phenomenon. On the post-workshop survey asking participants to rate the workshop, the mean score was 4.4 and the mode score was 5 on a scale of 1 (poor) to 5 (excellent).
Conclusion
Imposter phenomenon affects radiologists and is correlated with burnout. Innovative interventions to address imposter phenomenon such as workshops utilizing medical improvisational techniques are well-received.
Imposter phenomenon, first described by psychologists in the 1970s, refers to feelings of inadequacy and self-doubt due to an inability to internalize evident success and skill.
Also referred to as “imposter syndrome”, imposter phenomenon is not a “symptom” that needs to be “cured”; in some individuals, in fact, imposter phenomenon can actually be a motivational driver of success. In others, however, imposter phenomenon can exert a toll on well-being and impede career development. Prior studies have demonstrated an association between imposter phenomenon and stress, anxiety, and depression.
Given widespread and escalating rates of physician burnout (defined as emotional exhaustion, depersonalization, and cynicism secondary to prolonged work-related stress), innovative multifaceted strategies to promote wellness are necessary.
One such innovative strategy is application of improvisational theater (or “improv”), which is a form of theater where a live performance is unscripted, promoting spontaneous dialog. Improv is a burgeoning method of promoting engagement, team building, and personal confidence that has been applied in a variety of occupational settings. “Medical improv” has been used in some medical schools to teach students professional development skills such as communication, teamwork, and mental agility.
Learning through play and with laughter naturally sparks collaboration and decreases stress, thereby improving wellness of participants and fostering a sense of community.
We hypothesize that medical improv is an innovative method of addressing imposter phenomenon in radiologists.
While prior publications have investigated the prevalence of imposter phenomenon in medical students and select clinical subspecialties, there is limited literature specific to radiologists.
The purpose of our study was (1) to determine the prevalence of and perspectives on imposter phenomenon in radiologists at our institution, (2) to assess correlation between imposter phenomenon and burnout, and (3) to pilot an intervention aimed at addressing imposter phenomenon through medical improv techniques.
2. Methods
2.1 Part 1: imposter phenomenon in radiologists
IRB approval was obtained. An anonymous voluntary on-line survey was sent to clinical radiology faculty at a single academic medical center (Appendix A). No identifiable data was collected. A single question derived from the validated Mini-Z assessment tool was used to assess burnout. Survey data was collected via Google Survey. Statistical analysis was performed. Pearson chi-square test was used to determine correlation between imposter phenomenon and gender, imposter phenomenon and faculty experience, and imposter phenomenon and burnout, with significance level set at p < 0.05.
2.2 Part 2: intervention pilot
Funding was awarded through an internal institutional wellness grant. We developed an innovative workshop on imposter phenomenon utilizing techniques and strategies of improvisational theater. The goals of the workshop were to introduce the concept of imposter phenomenon, provide reframing exercises for imposter feelings, and promote teamwork and wellness within the department. Of note, the workshop was not designed to “cure” imposter phenomenon but rather to provide information and tools to individuals to help them benefit from imposter feelings and optimize mentorship of others who may be undermined by imposter phenomenon. All physicians in the radiology department at our academic medical center were invited to attend a 1-hour workshop. The workshop began with administration of the Clance Imposter Phenomenon Scale (CIPS), a validated 20-question tool developed by Dr. Pauline Rose Clance.
Permission to utilize the CIPS for this study was obtained directly from Dr. Clance. Key elements of the workshop were an introductory presentation on imposter phenomenon and burnout, paired partner activities regarding the “yes, and…” principle, and individual values affirmation exercises. A post-workshop survey was administered to assess participant rating of the workshop.
3. Results
3.1 Part 1: imposter phenomenon in radiologists
There were 30 respondents for the on-line survey (response rate 40%). Demographics of respondents was 37% (11/30) female and 63% male (19/30), 43% faculty <10 years (13/30) and 57% faculty >10 years (17/30). Of all participants, 83% (25/30) reported feelings of imposter phenomenon at some point during their career with a frequency of sometimes, often, or always (Table 1). Of those who had experienced imposter phenomenon, 84% (21/25) experienced it as an attending and 72% (18/25) experienced it during medical training including medical school, internship, and residency (Fig. 1). 10 respondents shared examples of imposter syndrome in an open box format. Select answers include:
Table 1On-line survey results.
Question
Never
Rarely
Sometimes
Often
Always
Have you experienced imposter phenomenon during your medical career?
n = 5
n = 3
n = 11
n = 9
n = 2
When you experienced feelings of imposter phenomenon, do you think it contributed to burnout?
n = 4
n = 5
n = 9
n = 6
n = 1
Question
Definitely no
Probably no
Maybe
Probably yes
Definitely yes
Do you think that imposter phenomenon is common in radiologists?
n = 0
n = 4
n = 15
n = 7
n = 3
Do you think imposter phenomenon is something our institution should address?
Fig. 1Survey results regarding timing of feelings of imposter phenomenon in radiologists (30 survey participants; 25 participants answered this question. Survey participants were asked to select all that apply).
“Voicing my opinion at meetings or conferences with other doctors who were for the most part male, older than me, and louder than me”
“Frequently as a resident and fellow I felt like I was pretending I knew more than I actually did and that the faculty all knew it too. Sometimes I still feel this as an attending. This perception makes me feel like interactions with my faculty and peers are disingenuous (on both my and their part)”
“Giving talks to peers”
Feelings of imposter phenomenon (sometimes, often, or always) were not significantly correlated with gender or with number of years on faculty. 40% (10/25) of respondents who reported experiencing imposter phenomenon identified insufficient mentorship as a contributing factor towards imposter syndrome and 24% (6/25) reported implicit bias/discrimination/inequity as an external contributing factor. Insufficient knowledge base (32%; 8/25) and insufficient experience (32%; 8/25) were also identified as contributing external factors (Fig. 2).
Fig. 2Survey results regarding factors contributing to feelings of imposter phenomenon in radiologists (30 survey participants; 25 participants answered this question. Survey participants were asked to select all that apply).
In regards to burnout, 47% (14/30) reported symptoms of burnout (definitely burning out, burnout won't go away, or completely burned out) as assessed by the validated Mini-Z tool (Fig. 3). Of 22 respondents who reported feelings of imposter syndrome sometimes, often, or rarely, 13 (59%; 13/22) also reported feelings of burnout (definitely burning out, burnout won't go away, or completely burned out). In contrast, only 1 out of the 8 (13%; 1/8) respondents who reported never or rarely experiencing feelings of imposter syndrome also endorsed feelings of burnout (definitely burning out). There was a significant (p = 0.024) correlation between imposter phenomenon and burnout (Fig. 4).
Fig. 3Survey results regarding distribution of burnout in radiologists (30 survey participants; 30 participants answered this question).
There were 30 members of the radiology department who participated in the pilot intervention workshop. The CIPS assessment tool, which was administered at the start of the workshop, was completed by 21 radiologists (the remaining 9 workshop participants arrived late and hence did not complete the CIPS assessment tool). Of the radiologists who completed the CIPS assessment tool, 71% (15/21) exhibited frequent or intense symptoms of imposter phenomenon. An additional 19% (4/21) experienced moderate symptoms of imposter phenomenon and 10% (2/21) experienced mild symptoms of imposter phenomenon (Fig. 5). During the workshop, there was 100% participation of attendees in interactive exercises. Results from the post-workshop survey are summarized in Table 2. There were 7 comments; positive comments entailed “Great workshop! Should be repeated.”, “Excellent! More please”, “Great initiative”, “Great job”, “Great! Helpful initiative about an important topic”; a single negative comment was “should be longer, go more in depth, more time for reflection/strategies”; and a single neutral comment was “IS [imposter syndrome] is necessary to maintain success”.
Fig. 5Prevalence of Imposter phenomenon in radiologists participating in the workshop, based the Clance Imposter Phenomenon Scale (30 radiologists participated in the workshop; 21 radiologists completed the CIPS).
Imposter phenomenon is a fairly recently described psychological phenomenon where highly successful individuals fail to internalize their accomplishments and as a result develop chronic feelings of self-doubt and fraudulence.
There is a high rate of imposter phenomenon in medical professionals, which can sometimes impede professional development, career advancement, and well-being.
Our results support this finding, with 72% of respondents reporting feelings of imposter phenomenon during their medical training. Surprisingly, a higher percentage of respondents (84%) in our study reported experiencing imposter phenomenon as faculty radiologists. Feelings of imposter phenomenon were not associated with number of years on faculty. This is in contrast to a similar study of imposter phenomenon in general surgeons where trainees had higher imposter phenomenon CIPS scores compared to faculty.
Theoretical possibilities for high rates of imposter phenomenon amongst radiology attendings include the rapid pace of technological advancement in the field, a relative lack of positive reinforcement via patient interactions compared to other medical specialties, and the quick pace of daily workflow.
There is mixed prior literature on the impact of gender on imposter phenomenon. While some studies have found a higher prevalence of imposter phenomenon in women, there is a growing body of literature reporting equivalent rates of imposter phenomenon between men and women.
In our study, we found no association between gender and feelings of imposter phenomenon. Interestingly, limited prior literature on imposter phenomenon in radiologists has been primarily female-driven.
It is possible that women may be more inclined to recognize and speak out about feelings of imposter phenomenon. As such, future interventions regarding imposter phenomenon in radiologists should be mindful to be inclusive of genders.
Negative mental health outcomes such as stress and depression are associated with imposter phenomenon.
Burnout, a phenomenon of emotional exhaustion, depersonalization, and feelings of personal inadequacy secondary to prolonged work-related stress, is an escalating issue amongst physicians. Radiologists have some of the highest rates of burnout amongst all medical specialties.
Burnout can lead to both dire personal consequences, such as substance abuse, depression, and suicide, as well as negative patient and organizational consequences such as medical errors, decreased productivity, and high rates of physician turnover. Key drivers of burnout include excessive workload, lack of control, and insufficient rewards.
Since the interplay between burnout and imposter phenomenon is likely bidirectional, wellness efforts should consider imposter phenomenon and interventions targeted towards the work unit, such as a department, department section, or radiology group.
Imposter phenomenon can lead to avoidance of opportunities and thereby impact diversification of leadership.
While our study did not address ethnic and racial differences in survey data, the authors acknowledge that imposter phenomenon is connected with diversity and inclusion in healthcare. Furthermore, consequences of imposter phenomenon may be compounded by implicit bias, microaggressions, and retaliation that many women and underrepresented identities encounter at the workplace.
Bias and marginalization magnify feelings of self-doubt, which is not to the fault of the individual but rather to the system as a whole. Efforts to address implicit bias and healthcare inequities should acknowledge the role imposter phenomenon may play in hampering physician recruitment, promotions, and individual physician wellness. Physicians and healthcare leaders should be educated on the prevalence and cost of imposter phenomenon as well as strategies to mitigate its detrimental effects on diversity and inclusion.
In this study, we piloted a unique intervention – a grant-funded workshop on imposter phenomenon utilizing medical improv – which was well-attended by members of the radiology department. Medical improv is an engaging tool that can be used to address important issues related to imposter phenomenon, inclusion, burnout, and professional development.
Medical improv helps create an inclusive environment of belonging and acceptance, which is the first step in mitigating negative consequences of imposter phenomenon. Overall, there was positive feedback and ratings from participants on the post-workshop survey indicating that the workshop was successful in meeting our goals of introducing the concept of imposter phenomenon, providing reframing strategies, and promoting collaboration and wellness. Of note, our intention was not to “cure” or “treat” imposter phenomenon and hence a post-workshop CIPS was not administered.
Additional systemic strategies that may be helpful in addressing imposter phenomenon include formalized mentoring programs, transparency in career advancement milestones, diversification of leadership, and structured recognition platforms for physician achievements. Dr. Salazar's “5 R's” for imposter phenomenon may be helpful on the individual level: “Recognize it, Rational Thinking, Reframe, Ready, Repeat if recurrent”.
Therefore, the authors suggest that interventions targeted towards imposter phenomenon adopt a neutral tone, with attention to both minimizing negative consequences and maximizing potential benefits.
Limitations of our study include the self-reporting format and potential participation bias of the survey. Furthermore, our results are reflective of a single academic institution with a relatively small sample size and did not account for radiology sub-specialization. The paucity of prior literature on imposter phenomenon in radiologists and the lack of normative data in the general population are limiting factors to analysis of results. Further research on the impact of imposter phenomenon in radiologists is needed.
In conclusion, imposter phenomenon is an increasingly recognized condition amongst attending physicians and physicians in training. Our study confirms occurrence of imposter phenomenon in radiologists at a single institution, demonstrates a correlation with burnout, and introduces a novel workshop-based approach for addressing imposter phenomenon with medical improv. Future directions could include multi-institutional collaboration to further investigate imposter phenomenon and interventions.
Precis
Imposter phenomenon affects radiologists and is correlated with burnout.
Funding
Northwestern University YourLife Wellness Grant. A $500 grant was awarded by Northwestern University, sponsored by Human Resources, Well-being. The grant was used to fund the pilot interactive workshop. The sponsors did not have a role in study design, data collection, or writing of this paper.
Declaration of competing interest
None.
Acknowledgments
The authors would like to acknowledge Professor Katie Watson for inspiration and insight on improvisational theater and applications in the field of medical humanities.
Appendix A. On-line anonymous voluntary survey
Demographics: (Please circle the answer that applies to you)
I identify as: Female | Male | Other
I am a:
Faculty <5 years | Faculty 5–10 years | Faculty >10 years|
Survey:
1.
Using your own definition of “burnout,” please select one of the answers below:
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I enjoy my work. I have no symptoms of burnout.
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I am under stress, and don’t always have as much energy as I did, but I don’t feel burned out.
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I am definitely burning out and have one or more symptoms of burnout, e.g., emotional exhaustion.
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The symptoms of burnout that I am experiencing won’t go away. I think about work frustrations a lot.
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I feel completely burned out. I am at the point where I may need to seek help
Impostor phenomenon refers to feelings of inadequacy and self-doubt in high achieving individuals despite external evidence of their success. Many prominent figures have recently reported feelings of imposter syndrome including Maya Angelou, Michelle Obama, Tom Hanks, and Neil Armstrong. Imposter syndrome can manifest in several ways including:
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Difficulty accepting compliments and/or a tendency to discount your accomplishments when receiving praise
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Tendency to remember incidents in which you have not done your best more than those times when you have done your best
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Feeling like you give the impression that you are more competent than you really are or that you are not as capable as others think you are
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Feeling like your success may be due to luck (being in the right place at the right time or knowing the right people)
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Comparing yourself to others and feeling like they are more intelligent than you
2.
Have you ever experienced such feelings of imposter phenomenon during your medical career?
Can you share an example of when you most felt inadequate or experienced self-doubt despite having the qualifications to perform the task at hand? (e.g. New resident or senior in the ED, first year as an attending, presenting research, performing a new procedure, writing a research paper/grant, etc.) *If you include any identifying information in the open-response question, we will not include information that could identify you in any study reports and presentations. If we quote any statements you make in the open-response questions, we will make sure the statement is de-identified in any study reports and presentations.
7.
Do you think that Imposter phenomenon is common in radiologists?
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