‘Passenger announcement: Is there a doctor on board?’ Tackling impostor phenomenon in the transition from medical student to foundation doctor

Abstract

Imposter phenomenon (IP) is the internalised experience of self-doubt or mediocracy that leads an individual to believe they do not belong. IP is increasingly recognised across the medical field, from medical school to consultancy, but likely affects different groups to varying extents. The transition in role from medical student to junior doctor can be a time of particularly high stress and insecurities about one's ability can act as a trigger or exacerbator of IP. Foundation doctors can arm themselves against IP by first acknowledging its existence and then actively attempting to dismantle these flawed misconceptions, as well as accessing support and resources available ubiquitously through the foundation programme.

There are very few instances in life where I am rousable at 4 o'clock in the morning. Having only seconds before been sprawled across three seats on my uncomfortable crack-of-dawn flight, my eyes have sprung open, and I am very much awake.

It takes a few seconds for me to mentally confirm that the announcement was not a poorly timed dream. It takes a further moment for me to come to the dreadful realisation that I, 6 weeks into my foundation training, may well be the only qualified medical professional currently cruising at 5,000 feet. And somebody onboard is unwell.

By the time I summon the confidence to get to my feet, two other gentlemen, both looking rather fresher than I do, have already volunteered their services, and, as the most junior of our trio, I am thanked then hastily batted away.

I am hit by a wave of relief, guilt and disappointment and slink back into my seat.

When I retell this rather unheroic story to non-medic friends later on, they ask the question I've been trying to avoid asking myself ever since - ‘you're a doctor, why didn't you stay and help?’.

The answer is pretty straightforward: although I am certain I had learnt more about clinical medicine and patient care in the 6 weeks following Black Wednesday than I had during 6 years of medical school, I still didn't feel like a doctor. In fact, I felt the biggest fraud in the hospital.

First described by Clance, imposter syndrome, or imposter phenomenon (IP) as it is more technically known, is an experience where individuals feel they do not deserve a position or successes and, as a result, they fear they will eventually be uncovered as an imposter.¹ In medicine, imposter syndrome often manifests as the flawed assumption that one is having to work exceptionally hard to do or achieve what peers find easy, and that ultimately it will become apparent they are not smart enough or dedicated enough to survive in the medical field. In the highly selective, competitive environment of medical school and postgraduate training, we are constantly confronted with public success of others and, as a result, perceptions of our shortcomings can be inflated.

Simultaneously, protected by the hierarchical structure of medicine, senior colleagues are able to make belittling, besmirching or patronising comments to their juniors, reinforcing juniors’ beliefs that they do not meet the required standard.² A pervading culture, both internally and externally, is that excellence should be both effortless and expected, with students diminishing their own academic achievements or good grades as doing fine or just okay with the potential to destroy the credibility of those who haven't scored so highly.

It is generally assumed that, at medical school, students are all in a similar situation. All have met the entry requirements, and all are subject to the same standards of academic rigor to eventually qualify as foundation doctors. However, when it comes to IP, this universal experience does not necessarily translate into equal perceptions of self-worth.

The emergent literature on IP among medical professionals suggests more women experience clinically significant levels of imposter phenomenon than men, at undergraduate and trainee level.³ Other significant factors include age (postgraduate students tend to report lower rates of imposter syndrome than undergraduates beginning their studies at 18) ,⁴ coming from an ethnic minority, and being from a lower socioeconomic background.⁵ Moreover, interactions between these factors may compound to produce more-than-additive disadvantages among the most underrepresented groups at medical schools.

While the undergraduate medical community is congratulating itself on improving access to those traditionally excluded from the profession, it has done little to address how these entrenched biases and insecurities continue to affect doctors as they move further through their careers. The bulk of this work falls onto the newest generation of junior doctors. Therefore, acknowledging new stressors and addressing the complexities of IP is critical both for trainers and supervisors, but also the incoming cohort of foundation doctors, who should be at least aware of the following:

Transitioning from student to doctor encourages diffidence:

The transition from medical student to junior doctor can contribute to the onset or exacerbation of IP: there is a stark loss of the structure provided by medical school, which has carried most foundation doctors from secondary school into their early twenties, alongside an expectation to be responsible for one's own workload, professional development and ongoing education. Additionally, there is little discrimination from seniors and other healthcare professionals between a fresh-faced new graduate on Black Wednesday and an outgoing senior house officer. One can hit the ground running and still feel ten steps behind.

Postgraduate training is experiential:

In sharp contrast to the structured learning of medical school, postgraduate learning opportunities are more random and opportunistic. Significant variation between placement, specialties and supervision affects the availability of development opportunities. Even within a department, more confident individuals and those who prioritise self-interest are more likely to seek out and accept opportunities to learn new skills. These experiences require the individual to believe they can step up and perform a task adequately for the first time, which those with IP may struggle with. This can then further reinforce to suffers of IP that Dr X is better than me because they can do or have learnt something which I cannot.

IP and perfectionism are predictors of burnout and mental ill health among students and doctors:

Sinisterly, the literature highlights a correlation between maladaptive perfectionism and the ‘nothing but the best is good enough’ mentality of IP, with a statistically significant degree of burnout, depression and suicidal ideation.² A study by Henning et al, on healthcare students from the US found that stress and burnout was inversely correlated to academic year – the further through a course a student progressed, the more their mental health suffered.⁶ This seems at face value counterintuitive; stressors should decrease over time as a student accustomed to the university environment; however, this particular study implies that the uniquely high-pressured environment of medical school exacerbates feelings of impostorism that become more entrenched overtime. Gottlieb et al also point towards institutional culture both at undergraduate and trainee level as a cause of IP and burnout.⁷

Tackling imposter phenomenon begins internally by embracing its existence but externally, relies upon adequate support, positive affirmation and validation of success from others.

Fundamentally, the foundation programme is a training programme – it is designed to support doctors’ learning, for regularly accepting new challenges and for progressing from the role of a medical student to an independently practicing clinician. While benchmarks and assessments between medical schools vary, the standards, evidence and outcomes required for successful completion of ARCP at foundation year 1 and year 2 level are determined nationally, and, as such, are based on a generic achievable framework that ensures safe practice.

By recognising and beginning to challenge feelings of imposition, we can embrace the experience of being outside our comfort zone. There is nowhere for a foundation doctor to hide in the NHS. Therefore, addressing gaps in knowledge or skills early on can not only help plug these leaks, but also allows one to familiarise themselves with their own limits and normalise asking for help; key skills for healthcare professionals that are often overlooked. At the beginning of each foundation placement, the doctor is asked to identify areas for development within their Professional Development Plan – this can be a highly useful and therapeutic opportunity to identify and encounter learning needs, rather than shying away from them, and can be reviewed and revised at any time. Reciprocally, seniors can then provide targeted supervision and support for new tasks and challenges, to encourage learning and build confidence. For example, had I admitted my relative inexperience of arrest calls upon starting my placement, I may have avoided the impending sense of doom I felt every time my emergency bleep went off over those first few weeks in August.

What did help and I am most grateful for, however, were spaces to reflect with the team following traumatic events. While for many members of the arrest or emergency team, dealing with adverse outcomes is routine, registrars and consultants should maintain an awareness that foundation doctors are confronting such scenarios for the first time and all team members can benefit from debriefing and reflecting.

Additionally, all foundation doctors are assigned two consultant allies, an educational supervisor who follows and charts their progress across the entire academic year, and a clinical supervisor who rotates depending on the clinical specialty the doctor is working in. Herein exists a readily available network of seniors proficient in pastoral and clinical support, and should be the first point of contact for any junior doctor struggling with their new responsibilities. During scheduled supervisor meetings, it may be daunting for juniors to broach these difficult and personal topics, hence supervisors should be prepared to actively explore foundation doctors’ transition to work and sense of belonging, as well as being on the lookout for more subtle signs of a doctor struggling. Critically, this set-up ensures no junior doctor should feel unsupported or out of their depth, a useful reminder to always put on your own oxygen mask first.

The passenger in seat 14E was met by the medical team at Frankfurt airport and disembarked the plane in good spirits. I have since analysed the scenario so acutely that I have a management plan in place for almost every conceivable in-flight medical emergency (perfectionism pervades still) but have also vowed never to put my Dr title on my boarding pass.

Author contributions

Dr R Murphy Lonergan. Conceptualisation of idea, Review of current literature. Writing – draft, review and editing.

Declaration of competing interest

Nil conflicts of interest to declare.