Leadership and Impostor Syndrome in Surgery

Abstract

BACKGROUND:

Impostor syndrome is an internalized sense of incompetence and not belonging. We examined associations between impostor syndrome and holding leadership positions in medicine.

STUDY DESIGN:

A cross-sectional survey was distributed to US physicians from June 2021 to December 2021 through medical schools and professional organizations. Differences were tested with the chi-square test and t-test for categorical and continuous variables, respectively. Logistic regression was used to identify factors associated with holding leadership positions and experiencing impostor syndrome.

RESULTS:

A total of 2,183 attending and retired physicians were included in the analytic cohort; 1,471 (67.4%) were in leadership roles and 712 (32.6%) were not. After adjustment, male physicians were more likely than women to hold leadership positions (odds ratio 1.4; 95% CI 1.16 to 1.69; p < 0.001). Non-US citizens (permanent resident or visa holder) were less likely to hold leadership positions than US citizens (odds ratio 0.3; 95% CI 0.16 to 0.55; p < 0.001). Having a leadership position was associated with lower odds of impostor syndrome (odds ratio 0.54; 95% CI 0.43 to 0.68; p < 0.001). Female surgeons were more likely to report impostor syndrome compared to male surgeons (90.0% vs 67.7%; p < 0.001), an association that persisted even when female surgeons held leadership roles. Similar trends were appreciated for female and male nonsurgeons. Impostor syndrome rates did not differ by race and ethnicity, including among those underrepresented in medicine, even after adjustment for gender and leadership role.

CONCLUSIONS:

Female physicians were more likely to experience impostor syndrome than men, regardless of specialty or leadership role. Although several identity-based gaps persist in leadership, impostor syndrome among racially minoritized groups may not be a significant contributor. (J Am Coll Surg 2023;237:585–595. © 2023 by the American College of Surgeons. Published by Wolters Kluwer Health, Inc. All rights reserved.)

“Impostor syndrome” (also known as “impostor phenomenon”) is an internal experience of “intellectual phoniness” or undeserved success despite objective measures.¹ The phenomenon was first described in 1978 among a group of high-achieving and successful professional women and has since been demonstrated to be common across healthcare professionals.^1–4 Impostor syndrome is well documented among medical students, especially during clinical education,^5–11 and among post-graduate trainees across specialties, with higher rates observed among women.^12–16 Impostor syndrome has been associated with anxiety, burnout, suicidal ideation, and a lower sense of professional fulfillment.^2,7,13 In recent years, impostor syndrome has gained traction as a target for improving well-being and resilience among physicians and trainees.^17–19

Impostor syndrome is prevalent in surgical specialties, with rates as high as 76% reported among general surgery residents.^13,20–23 Although some studies have identified female gender and younger age as predictive factors for impostor syndrome in surgery, others report no differences across demographic dimensions.^20–23 These discrepancies in findings may be due to relatively small sample sizes or differences in study design. However, information about the prevalence and impact of impostor syndrome at the faculty level, particularly as it relates to those who are underrepresented in medicine (URIM), is scarce.²⁴ Literature on impostor syndrome among surgical faculty and those who hold leadership positions in medicine is even more limited.

In this study, we designed a cross-sectional online survey to evaluate impostor syndrome among faculty physicians in the US. Our secondary aims were to assess impostor syndrome among surgeons vs nonsurgeons, as well as the association between having a leadership role and experiences of impostor syndrome. We hypothesized that rates of impostor syndrome would, in general, be high, with higher rates observed among surgeons compared to those not in surgery. We hypothesized there would be higher rates of impostor syndrome in surgical fields due to additional areas of competency assessments (eg operative skills) compared to nonsurgical specialties. We also hypothesized that holding a leadership role would be a protective factor against impostor syndrome, while identifying as a woman or URIM would be a risk factor for impostor syndrome.

METHODS

Study design and population

All practicing and retired physicians in the US were eligible to participate. This study was part of a larger project designed to assess intergenerational influences in medicine, including responses from medical students and trainee physicians. However, no students or trainees were included in this analysis. The study was reviewed and determined exempt by the Duke University (Pro00108612), University of North Carolina (IRB #22–1122), and University of Pennsylvania (#849640) institutional review boards.

Survey development

A cross-sectional survey was developed by a multidisciplinary team. A survey expert at the Odum Institute for Research in Social Science was consulted throughout the survey development process. The survey was formatted in Qualtrics XM (Qualtrics, Provo, UT) and made compatible for viewing on desktop and mobile devices. Display and skip logic within the survey platform were used to mask inapplicable questions depending on the respondent’s answers. The survey was piloted with a diverse cohort of individuals, and feedback on survey content, language, flow, and user experience were solicited. A Qualtrics expert at the Odum Institute for Research in Social Science also reviewed the survey and provided feedback on user accessibility. Edits were iteratively made during the pilot phase through discussion with the research team. A finalized version of the survey was tested by all members of the primary research team.

The survey included a total of 41 items, including demographic characteristics, educational background, training, current practice, leadership roles, and experiences of impostor syndrome. Question formats included multiple choice, Likert scale, and free response. URIM included individuals who were Hispanic, non-Hispanic Black, or non-Hispanic other (individuals who selected only American Indian/Alaskan Native, Hawaiian/Other Pacific Islander, Other, or “choose not to disclose”). Citizenship was categorized as US citizen, permanent resident (ie green card holder), and US visa holder (eg physician from abroad on an approved US work visa). Leadership role was assessed using a multiple-choice question with the options: “Dean (including Associate Dean, Assistant Dean, Vice Dean),” “Chief/Chair (including Vice Chief/Chair),” “Center Director,” “Practice Partner,” “Chief of Staff,” “Program Director,” and “Other” (see Supplemental Digital Content 1, http://links.lww.com/JACS/A284).

The primary goal with impostor syndrome questions was to assess participants’ perception of their impostor syndrome. Feelings of how often impostor syndrome is experienced were collected on a 5-item Likert scale ranging from “I have never experienced impostor syndrome” to experiencing impostor syndrome “All the time.” Participants reporting “I have never experienced impostor syndrome” or “Almost never” were grouped as “Almost Never to Never” and those reporting “Sometimes,” “Almost all the time,” or “All the time” were grouped as “Sometimes to All the Time.” The following standard definition of “impostor syndrome” was provided in the survey: Impostor syndrome can be defined as a collection of feelings of inadequacy that persist despite evident success.²⁵ A hyperlink to a resource on impostor syndrome was provided for more context.²⁵

Current survey instruments assessing impostor syndrome include the 20-question Clance Impostor Phenomenon (IP) Scale,²⁶ 14-question Harvey Impostor Scale,²⁷ 51-question Perceived Fraudulence Scale,²⁸ and the 7-question Leary Impostor Scale.²⁹ Although the Clance IP Scale is most commonly cited, psychology literature does not readily agree on a gold standard.³⁰ This survey was part of a larger study where the primary focus was family ties to medicine and soliciting more granular information about demographic and social upbringing; thus, inclusion of an additional 7 to 51 questions on impostor syndrome alone was anticipated to substantially increase the length of the survey and reduce our response rate. The Likert scale questions mentioned earlier were ultimately selected through survey pilot process, iterative revisions, and consultation with survey experts.

Survey administration

The survey was administered from June 2021 to December 2021. Surveys were distributed through professional organizations and medical schools. For professional organizations, a formal survey proposal was submitted through the appropriate channel for approval. For medical schools, a standardized introductory email was sent to the Vice Dean of Faculty Affairs or equivalent role at all allopathic and osteopathic medical schools in the US. One follow-up email was sent if there was no response. After survey approval, for organizations and medical schools that allowed multiple emails to be sent, one initial email and one reminder email were sent to all participants.

To avoid duplicate responses from participants who received the survey through multiple professional organizations and their home institution, the survey platform was programmed to flag any submissions received from the same IP address. All flagged responses were reviewed by a member of the research team (YI) and removed if they were identified as a duplicate response. An additional Bot detection tool was used to flag suspicious responses.

The need for informed consent was waived for this study. However, at the beginning of the survey, participants were informed about the general goals of the survey, risks, and benefits, and were given the option to proceed with the survey at that time. At the end of the survey, participants had the option of being entered into a drawing for a $100 gift card. Email addresses for the gift card drawing were stored separately from the survey data. All survey responses were anonymous. The survey was voluntary, and no participants were compensated.

Statistical analysis

Categorical variables were summarized with n (%) and continuous variables were summarized with median (interquartile range). Select differences were tested using the chi-square or Fisher’s exact test for categorical variables or the t-test for continuous variables. Logistic regression was used to identify factors associated with holding a leadership position and feeling impostor syndrome. Odds ratios (ORs) and 95% CIs are reported. Primary models included the following covariates: gender identity, URIM, citizenship, parents born in the US, began/completed any undergraduate medical education outside the US, any family in medicine, and specialty type. The impostor syndrome models also included leadership position. Sensitivity analyses were also conducted with race and ethnicity in place of URIM. Because the results of these models did not differ from the primary model, only primary model results are reported here.

Responses of “Choose not to disclose” were treated as missing data for all statistical analyses. Only participants with complete data were included in each analysis. No adjustments were made for multiple comparisons. All statistical analyses were conducted using SAS, version 9.4 (SAS Institute, Cary NC).

RESULTS

Of the 183 professional organizations and 198 medical schools that were contacted, 19 professional organizations and 21 medical schools agreed to share our survey with faculty-level physicians. The survey response rate was calculated for organizations and programs that shared the survey through email. Newsletters and bulletin postings were not included because of the inability to track the number of participants who received the information. An approximated total of 29,082 emails were sent (23,621 from professional organizations, 5,461 from medical schools) for an approximated response rate of 7.5% (2,183 participants/29,082 total emails). Notably, one professional organization and 12 medical schools were either unable to verify the method of survey distribution or the total number of email recipients due to lack of data.

Demographic characteristics of participants are outlined in Table 1. The median age was 48 years, and our cohort was 52.6% female, 73.7% non-Hispanic White, and 11.3% identified as URIM. The majority (96.7%) were US citizens. Individuals who were in a surgical specialty comprised 25.5% of the cohort (n = 557), and this decreased to 22.2% (n = 464) when excluding obstetrics and gynecology. Of the total participants, 67.4% reported being in some type of leadership role.

Table 1.

Characteristics of Respondents by Leadership Position

Variable	All participants (N = 2183)	Leadership position		p Value
		No (n = 712)	Yes (n = 1471)
Age, y, median (IQR)	48 (39–60)	40 (36–49)	52 (43–62)
Gender identity, n (%)				0.001
Cisgender female/woman	1148 (52.6)	412 (35.9)	736 (64.1)
Cisgender male/man	987 (45.2)	283 (28.7)	704 (71.3)
Transgender/nonbinary/other	15 (0.7)	7 (46.7)	8 (53.3)
Race, n (%)				0.006
Non-Hispanic White	1608 (73.7)	493 (30.7)	1115 (69.3)
Non-Hispanic Black	83 (3.8)	25 (30.1)	58 (69.9)
Non-Hispanic Asian	276 (12.6)	110 (39.9)	166 (60.1)
Non-Hispanic other	57 (2.6)	19 (33.3)	38 (66.7)
Non-Hispanic multiple races	52 (2.4)	25 (48.1)	27 (51.9)
Hispanic	107 (4.9)	40 (37.4)	67 (62.6)
Underrepresented in medicine, n (%)				0.62
No	1936 (88.7)	628 (32.4)	1308 (67.6)
Yes	247 (11.3)	84 (34.0)	163 (66.0)
Citizenship, n (%)				0.001
Yes, US citizen	2110 (96.7)	679 (32.2)	1431 (67.8)
No, permanent resident (green card holder)	42 (1.9)	17 (40.5)	25 (59.5)
No, US visa holder (H-1B, H-2B, J-1, F-1, etc)	20 (0.9)	14 (70.0)	6 (30.0)
Surgical specialty, n (%)				<0.001
No	1626 (74.5)	564 (34.7)	1062 (65.3)
Yes	557 (25.5)	148 (26.6)	409 (73.4)
Surgical specialty (excluding OBGYN), n (%)				<0.001
No	1626 (77.8)	564 (34.7)	1062 (65.3)
Yes	464 (22.2)	119 (25.6)	345 (74.4)

Data presented as n (%) unless otherwise specified. Row percentages are reported for Leadership Position Yes and No estimates and column percentages are reported for All Participants.

IQR, interquartile range; OBGYN, obstetrics and gynecology.

Leadership in medicine

Participants in leadership roles differed significantly by demographic characteristics (Fig. 1). Men were more likely than women to hold leadership roles (71.3% vs 64.1%; p < 0.001). Rates of holding a leadership role were similar among non-Hispanic Black (69.9%), non-Hispanic White (69.3%), Other (66.7%), Hispanic (62.6%), and Asian (60.1%) respondents (p = 0.06). Being URIM was also not associated with holding a leadership role compared to non-URIM (67.6% vs 66.0%; p = 0.62). However, being a US citizen (67.8%) was associated with holding a leadership role compared to permanent residents (59.5%) and US visa holders (eg physician on an approved US work visa; 30.0%; p = 0.001). Among respondents, being in a surgical specialty was associated with being in a leadership role (73.4% vs 65.3%; p < 0.001), and this remained true when obstetrics and gynecology were excluded (74.4% vs 65.3%; p < 0.001). Similar associations were maintained after adjustment for covariates. The distribution of individuals in leadership roles is visualized by proportion in Figure 1A and by absolute frequency in Figure 1B. Both figures are broken down by race and gender.

Figure 1.

(A) Leadership position in proportions by race and ethnicity and gender identity. (B) Leadership position in frequencies by race and ethnicity and gender identity.

Race, ethnicity, and gender characteristics were evaluated across leadership position types and are summarized in Tables 2 to 8. Medical school deans were predominantly non-Hispanic White (75.7%) with similar female vs male breakdown (47.1% vs 51.4%; Table 2). The role of Chief or Chair was mostly White (74.4%) and male (58.8%; Table 3). Center directors were also mostly White (76.9%), but had similar gender proportions among female and male physicians (47.2% vs 49.1%; Table 4). Practice partner was largely White (72.5%) and male (55.1%; Table 5). Chief of staff had the highest proportions of White (85.4%) and male leaders (66.7%; Table 6). Program directors followed these trends for White race (79.9%), but had similar rates of women and men (49.3% vs 48.5%; Table 7). Those who indicated “Other” for leadership position were also predominantly White (73.6%) and included higher proportions of women vs men (58.7% vs 39.9%; Table 8).

Table 2.

Gender Identity and Race and Ethnicity by Leadership Role – Dean

Variable	Race and ethnicity						Total
	Hispanic	Non-Hispanic Asian	Non-Hispanic Black	Non-Hispanic multiple races	Non-Hispanic other	Non-Hispanic White
Gender identity
Cisgender female/woman	1 (1.4)	1 (1.4)	3 (4.3)	0 (0)	0 (0)	28 (40)	33 (47.1)
Cisgender male/man	2 (2.9)	6 (8.6)	2 (2.9)	1 (1.4)	0 (0)	25 (35.7)	36 (51.4)
Total	3 (4.3)	7 (10)	5 (7.1)	1 (1.4)	1 (1.4)	53 (75.7)	70 (100)

Data presented as n (%). All percentages are out of total number of participants indicating leadership role. Percentages may not add up to 100 due to rounding or missing values.

Table 8.

Gender Identity and Race and Ethnicity by Leadership Role – Other

Variable	Race and ethnicity						Total
	Hispanic	Non-Hispanic Asian	Non-Hispanic Black	Non-Hispanic multiple races	Non-Hispanic other	Non-Hispanic White
Gender identity
Cisgender female/woman	17 (3.5)	33 (6.8)	19 (3.9)	7 (1.5)	6 (1.2)	202 (41.7)	284 (58.7)
Cisgender male/man	5 (1)	25 (5.2)	8 (1.7)	1 (0.2)	4 (0.8)	150 (31)	193 (39.9)
Transgender/nonbinary/other	0 (0)	0 (0)	0 (0)	1 (0.2)	1 (0.2)	2 (0.4)	4 (0.8)
Total	22 (4.6)	58 (12)	27 (5.6)	9 (1.9)	12 (2.5)	356 (73.6)	484 (100)

Data presented as n (%). All percentages are out of total number of participants indicating leadership role. Percentages may not add up to 100 due to rounding or missing values.

Table 3.

Gender Identity and Race and Ethnicity by Leadership Role – Chief/Chair

Variable	Race and ethnicity						Total
	Hispanic	Non-Hispanic Asian	Non-Hispanic Black	Non-Hispanic multiple races	Non-Hispanic other	Non-Hispanic White
Gender identity
Cisgender female/woman	9 (2.3)	19 (4.9)	6 (1.5)	2 (0.5)	5 (1.3)	106 (27.1)	147 (37.6)
Cisgender male/man	13 (3.3)	25 (6.4)	4 (1)	3 (0.8)	4 (1)	181 (46.3)	230 (58.8)
Transgender/nonbinary/other	0 (0)	0 (0)	0 (0)	0 (0)	2 (0.5)	0 (0)	2 (0.5)
Total	22 (5.6)	46 (11.8)	10 (2.6)	5 (1.3)	17 (4.4)	291 (74.4)	391 (100)

Data presented as n (%). All percentages are out of total number of participants indicating leadership role. Percentages may not add up to 100 due to rounding or missing values.

Table 4.

Gender Identity and Race and Ethnicity by Leadership Role – Center Director

Variable	Race and ethnicity						Total
	Hispanic	Non-Hispanic Asian	Non-Hispanic Black	Non-Hispanic multiple races	Non-Hispanic other	Non-Hispanic White
Gender identity
Cisgender female/woman	3 (1.4)	9 (4.3)	4 (1.9)	3 (1.4)	5 (2.4)	76 (35.9)	100 (47.2)
Cisgender male/man	4 (1.9)	10 (4.7)	3 (1.4)	1 (0.5)	2 (0.9)	84 (39.6)	104 (49.1)
Transgender/nonbinary/other	0 (0)	0 (0)	0 (0)	0 (0)	1 (0.5)	0 (0)	1 (0.5)
Total	7 (3.3)	19 (8.9)	7 (3.3)	4 (1.9)	12 (5.7)	163 (76.9)	212 (100)

Data presented as n (%). All percentages are out of total number of participants indicating leadership role. Percentages may not add up to 100 due to rounding or missing values.

Table 5.

Gender Identity and Race and Ethnicity by Leadership Role – Practice Partner

Variable	Race and ethnicity						Total
	Hispanic	Non-Hispanic Asian	Non-Hispanic Black	Non-Hispanic multiple races	Non-Hispanic other	Non-Hispanic White
Gender identity
Cisgender female/woman	5 (2.8)	11 (6.2)	4 (2.3)	3 (1.7)	2 (1.1)	50 (28.1)	75 (42.1)
Cisgender male/man	5 (2.8)	10 (5.6)	1 (0.6)	3 (1.7)	1 (0.6)	78 (43.8)	98 (55.1)
Total	11 (6.2)	21 (11.8)	5 (2.8)	6 (3.4)	6 (3.4)	129 (72.5)	178 (100)

All percentages are out of total number of participants indicating leadership role. Percentages may not add up to 100 due to rounding or missing values.

Table 6.

Gender Identity and Race and Ethnicity by Leadership Role – Chief of Staff

Variable	Race and ethnicity						Total
	Hispanic	Non-Hispanic Asian	Non-Hispanic Black	Non-Hispanic multiple races	Non-Hispanic other	Non-Hispanic White
Gender identity
Cisgender female/woman	0 (0)	0 (0)	0 (0)	0 (0)	0 (0)	14 (29.2)	14 (29.2)
Cisgender male/man	2 (4.2)	2 (4.2)	0 (0)	1 (2.1)	1 (2.1)	26 (54.2)	32 (66.7)
Total	2 (4.2)	2 (4.2)	0 (0)	1 (2.1)	2 (4.2)	41 (85.4)	48 (100)

Data presented as n (%). All percentages are out of total number of participants indicating leadership role. Percentages may not add up to 100 due to rounding or missing values.

Table 7.

Gender Identity and Race and Ethnicity by Leadership Role – Program Director

Variable	Race and ethnicity						Total
	Hispanic	Non-Hispanic Asian	Non-Hispanic Black	Non-Hispanic multiple races	Non-Hispanic other	Non-Hispanic White
Gender identity
Cisgender female/woman	6 (1.3)	35 (7.6)	11 (2.4)	3 (0.7)	1 (0.2)	170 (37.1)	226 (49.3)
Cisgender male/man	5 (1.1)	19 (4.2)	3 (0.7)	4 (0.9)	2 (0.4)	189 (41.3)	222 (48.5)
Transgender/nonbinary/other	0 (0)	0 (0)	0 (0)	0 (0)	0 (0)	2 (0.4)	2 (0.4)
Total	11 (2.4)	54 (11.8)	14 (3.1)	7 (1.5)	6 (1.3)	366 (79.9)	458 (100)

Data presented as n (%). All percentages are out of total number of participants indicating leadership role. Percentages may not add up to 100 due to rounding or missing values.

Impostor syndrome

Factors associated with experiencing impostor syndrome are summarized as a forest plot in Figure 2. Logistic regression revealed that men had lower odds of experiencing impostor syndrome (OR 0.31; 95% CI 0.25 to 0.38; p < 0.001). Being a nonpermanent resident or US visa holder was associated with higher odds of impostor syndrome (OR 2.66; 95% CI 1.22 to 5.8; p = 0.01); however, starting or completing undergraduate medical education outside the US was associated with lower odds of impostor syndrome (OR 0.48; 95% CI 0.32 to 0.71; p < 0.001). Identifying as URIM, having parents born outside the US, and having family members in medicine (parents, grandparents, aunts, uncles) were not associated with odds of experiencing impostor syndrome.

Figure 2.

Forest plot of adjusted logistic regression model predicting experiencing impostor syndrome sometimes to all the time vs almost never to never (N=2130). Estimates summarized in this figure are also adjusted for citizenship, parents born in the US, begin/complete any undergraduate medical education outside the US, and any family in medicine. OR, odds ratio; URM, underrepresented minority.

Leadership, impostor syndrome, and surgery

After adjustment for other covariates, being in a surgical vs nonsurgical specialty was not associated with experiencing impostor syndrome (p = 0.53). However, being in a leadership position was associated with lower odds of impostor syndrome (OR 0.54; 95% CI 0.43 to 0.68; p < 0.001). When looking at male vs female surgeons, female surgeons were more likely to report impostor syndrome compared to male surgeons (90.0% vs 67.7%; p < 0.001). Similar trends were appreciated for female and male nonsurgeons, where female nonsurgeons had higher rates of impostor syndrome than their male counterparts (88.7% vs 72.0%; p < 0.001).

We also examined whether female surgeons in leadership roles were more or less likely to experience impostor syndrome than male surgeons in leadership roles. Indeed, female surgeons had higher rates of impostor syndrome compared to male surgeons in leadership roles (81.5% vs 54.6%; p < 0.001). When comparing female surgeons to female nonsurgeons in leadership roles, there was no significant difference in imposter syndrome (79.5% vs 81.5%; p = 0.67).

DISCUSSION

In this national survey of fully trained physicians, leadership and impostor syndrome differed across demographic characteristics including gender and specialty. Men, US citizens, and surgeons were more likely to be in leadership positions. Male physicians had lower odds of impostor syndrome compared to female physicians, regardless of whether they were in surgical specialties. These associations persisted even when female surgeons and nonsurgeons held leadership roles. This is the first study to our knowledge that assesses the relationship between leadership and impostor syndrome.

The persistent gender disparities demonstrated in this study align with existing literature reporting higher rates of impostor syndrome among women.^2,8,22,23,31 One explanation for this is that women experience more bias, mistreatment, and workplace harassment, which may cause them to internally call into question their place in medicine, particularly as it relates to holding a leadership role.^32,33 Despite achieving gender parity among medical students, women remain underrepresented at the levels of full professor, department chair, and dean.^34,35 A 2021 qualitative study of female physicians’ experiences with promotion in academic medicine yielded several common themes, including malicious behavior from male colleagues, seeing men with lesser accomplishments advance, and receiving explicit messages that tenure decisions were related to their gender.³⁶ Although pay was outside the scope of this study, persistent pay inequities may be an additional contributor to impostor syndrome and an important factor to consider in future studies.^37–40 It is possible that the few women who reach leadership roles continue to face barriers that reinforce thoughts of impostor syndrome, no matter how high they ascend.

We observed no significant differences in leadership or impostor syndrome when analyzing participant racial and ethnic identity, including those who identified as URIM. These findings are consistent with previous studies that reported no differences in impostor syndrome by race.^13,20 However, it is well-documented that racial diversity among academic leadership is lacking and still predominantly White and male.^41–44 Our findings suggest that impostor syndrome may not be a significant contributor to the lack of racial and ethnic diversity observed in medical leadership, suggesting that the primary drivers to racial and ethnic leadership disparities are systemic in nature.⁴⁵

Our findings also underscore the ongoing need for targeted and intentional support of those who are at higher risk of experiencing impostor syndrome. Impostor syndrome has been associated with anxiety and burnout,^2,7,13 and is observed at higher rates among female faculty.^46,47 Several interventions have emerged to reduce impostor syndrome and its associated sequelae. For instance, in an online group-coaching program for female residents, professional coaching decreased impostor syndrome scores and increased self-compassion scores.¹⁷ Another curriculum for residents demonstrated increased wellness and awareness of impostor syndrome after participation in an impostor syndrome–specific discussion.¹⁹ Although these interventions have predominantly focused on trainees, ongoing attention is needed to promote awareness of impostor syndrome and the need for both mentorship and self-compassion for faculty.⁴⁸ Continuous professional development through peer mentoring and video-based surgical coaching programs show promise for providing accessible support to faculty at various levels of training and in diverse geographic settings.^49,50 Addressing systemic drivers of inequity in the workforce, such as working toward pay parity, are crucial alongside these more proximal interventions to ensure sustainable progress.^37,51

It is also worth considering the potential benefits of impostor syndrome in moderation. The opposite of impostor syndrome, called the “Dunning-Kruger effect,” describes individuals who overestimate their true abilities.⁵² A previous study on physicians’ perceptions of their performance reported that individuals who performed highly were more likely to underestimate their knowledge, but those with poorer performance significantly overestimated their knowledge.⁵³ Impostor syndrome may be more favorable than overconfidence, especially in certain high-stakes environments or decision-making processes. It is possible that some respondents who reported never experiencing impostor syndrome in our survey—in which 30% fewer men in leadership positions reported experiencing impostor syndrome compared to women in leadership positions—may routinely overestimate their abilities or knowledge. However, there is currently no meaningful way of assessing the degree of impostor syndrome vs overestimation among physicians.

Impostor syndrome is also likely tied to lack of diversity among leaders. Individuals who see fewer people who look like themselves in leadership positions may feel less supported or out of place, which may contribute to a greater sense of impostor syndrome and lack of belonging. We suspect that improved diversity in medical ranks will be associated with decreased impostor syndrome, especially among racial and ethnic minorities and female physicians. There is room for exploration of these elements to better understand and prepare individuals for successful careers in medicine and leadership while maintaining wellness.

Limitations

This study has several limitations. First, we were not able to accurately calculate a response rate and our estimate was low. In other studies, survey responses among physicians range from approximately 8% to 40%, putting this study with a response rate of 7.5% at the lower end.^54–56 The response rate may be due to the timing in which it was administered (during an early phase of the COVID-19 pandemic when reports of administrative fatigue were high).^57,58 The low response rate during the pandemic is consistent with studies that have reported response rate predictions based on physician survey fatigue.⁵⁹ We were also limited by the number of organizations and programs that did not have access to listserv email counts or were unable to verify the method of survey distribution due to staff turnover and inadequate documentation. Finally, we were unable to account for individuals who received the email multiple times through professional organizations and their home institution, increasing the denominator of individuals who could potentially respond.

Due to challenges with calculating an accurate response rate, it was difficult to assess the generalizability of our cohort. Compared to the 2018 report of active US physicians, our cohort was more White (73.7% vs 56.2%) and female (52.6% vs 35.8%).^60,61 Our cohort was closer in demographics to full-time US medical school faculty for proportions of White (73.7% vs 63.9%) and female (52.6% vs 41.0%) physicians.^62,63 This is likely due to survey reach and more robust response rate among certain identity-based organizations (eg Association of Women Surgeons). We tried to improve the generalizability of our cohort by contacting all US medical schools to capture wide geographic spread and asked for emails to be sent to affiliate or community physician groups when possible. We also sent multiple reminder emails and offered a gift card drawing to increase the response rate.⁶⁴

The survey is subject to selection bias, which may explain the high proportion of individuals in leadership positions in our study. The high proportion of leaders in this study may also be related to the framing of the survey itself, which was part of a larger study on intergenerational influences in medicine. Although we collected a free-text response for those who selected “Other” for their leadership position, we were unable to make additional categories of leadership to meaningfully assess different types and levels of leadership engagement. This information may have yielded valuable insight into types of leadership among women, because it was the only category with higher proportions of women leaders. To prioritize survey length and avoid participant fatigue, we did not use a traditionally validated survey for impostor syndrome. Assessing which impostor syndrome scale (among the Clance IP Scale, Harvey Impostor Scale, Perceived Fraudulence Scale, and Leary Impostor Scale) would be best suited for surveying physicians in leadership was outside the scope of this study; however, future directions include assessing which existing instrument(s) would be most conducive for surveying health professionals and those in leadership. Additional studies are needed to investigate how to address disproportionate rates of impostor syndrome among certain groups of physicians. Although doing so was beyond the scope of our current study, examination of these subgroups may benefit from in-depth qualitative interviews or focus groups in the future. Finally, this is a cross-sectional analysis and causal inferences cannot be made.

CONCLUSIONS

This study confirmed that gender gaps are prevalent in medical leadership. Female physicians were more likely to experience impostor syndrome than male physicians whether they were in surgery or not and regardless of whether they held a leadership role. However, although several identity-based gaps persist in leadership, impostor syndrome among racially minoritized groups may not be a significant contributor. More work is necessary to support physicians who are at higher risk of impostor syndrome through individual- and system-level interventions.