Investigating feelings of imposterism in first‐year medical student narratives

Abstract

Introduction

Imposter phenomenon (IP), feeling as if a person does not belong, has been reported in medical students at various rates. In medical literature, this phenomenon has often been defined as a ‘syndrome’, but other studies have described it as a dynamic experience that can have various impacts on different people at different time points. Although studies have linked IP with other phenomena such as burnout in residents and physicians, no studies have examined its aetiology nor how these feelings are experienced by medical students.

Methods

With the use of social identity theory as a framework, the authors analysed 233 reflective essays for elements of IP across eight cohorts of medical students from two institutions. Students responded to a prompt that asked: ‘What was one part of your identity that you thought you would have to change in order to become a physician?’ Included reflections were analysed using the framework method.

Results

Elements of IP were identified in 121 reflections (52%) and were categorised into three major themes: (1) Comparing oneself to an idealised image of a medical student, (2) Comparing oneself to an idealised image of a physician and (3) Concerns about presentation of self to others. Each theme contained two or more sub‐themes. Commonly, students discussed how their own personality traits, experiences, backgrounds and identities cast doubt on their sense of belonging in medicine.

Discussion

The results of this study were consistent across both institutions, suggesting that imposter feelings are common among all first‐year medical students. However, the extent of the impact of these feelings on their identity formation depends on the individual lived experiences of students and the context in which these feelings arise. Encouraging reflective journaling and sharing of stories from all stages of education can normalise imposter feelings during the development of the professional identity as a physician.

Short abstract

Finding elements of imposter phenomenon in 52% of student reflections, much of it driven by self‐comparisons to idealizations, the authors argue that journaling can help normalize imposterism, aiding identity growth as future physicians.

1. INTRODUCTION

My great problem in life is that I do not really know what my role in life is. King Charles III ¹

Imposter phenomenon (IP) was originally described as the inability of an individual to accept that their successes are based on their abilities or intellect and instead attribute achievement to luck or a mistake. These individuals consider themselves imposters and fear they will be seen as incompetent when their ‘faking’ is discovered. ² , ³ Faking, or inauthenticity, distances oneself from their role and can influence one's feelings of belongingness in their profession, just as feeling ‘othered’ from their profession can initiate the imposter experience. ⁴ Such feelings can have a negative impact on the individual's career outcomes and overall psychological wellness. ² , ⁵ , ⁶ , ⁷

Studies of medical students and their experiences with IP are limited. Much of the existing literature examines the presence of IP in medical students based on prevalence, character traits and demographics, ⁸ , ⁹ , ¹⁰ , ¹¹ rather than the sources that may contribute to the formation of imposter feelings. A scoping review found the prevalence of IP ranges from 22% to 60%. Some studies have found significantly higher rates of IP in women, whereas others have found no gender‐based differences. ¹⁰ Other studies of medical students and residents indicate that IP is associated with higher rates of burnout, depersonalisation, depression and anxiety. ¹² , ¹³ , ¹⁴ Notably, one longitudinal quantitative study showed that across the first 3 years of medical education, there was a significant decrease in students' perceived identity as a physician, whereas their imposter feelings increased. ¹⁵

There is notable disagreement in the literature about the nomenclature surrounding feelings of being an imposter where some authors refer to these feelings as a ‘syndrome’, and others refer to them as a ‘phenomenon’. The difference in nomenclature is not merely semantic. For example, Merriam Webster defines a syndrome as ‘a group of signs and symptoms that occur together and characterise a particular abnormality or condition’. ¹⁶ By contrast, the same source defines a phenomenon as, ‘a fact or event of scientific interest, susceptible to scientific description and explanation’. ¹⁷ Based on these two definitions, the word syndrome implies that feelings of being an imposter are somehow pathological or abnormal and open to treatment, and the word phenomenon simply describes a state of affairs without assigning it clinical or diagnostic significance. In the medical literature, imposter syndrome is the term most often used to describe feelings of being an imposter, thus pathologising the individual experiencing these feelings. ¹⁰ , ¹⁸ As a result, many of the proposed ‘treatments’ for imposter syndrome promote self‐help remedies and therapy as opposed to focusing on sources that may contribute to imposter feelings. ¹⁹ , ²⁰ , ²¹ Importantly, as recently as 2020, a systematic review found, ‘no published review of the evidence to guide the diagnosis or treatment of patients presenting with imposter syndrome’ (p. 1252 ¹¹ ). Given the lack of information on how imposter feelings are experienced, we have chosen in this study to treat feelings of being an imposter as a phenomenon worthy of further scientific inquiry.

At the same time that imposter feelings manifest at the individual level, it is important to consider the impact of social context and the cultural milieu in which the individual exists. ²² , ²³ McElwee and Yurak, for example, view IP as a dynamic psychological experience that can impact a variety of individuals as a result of contextual influences. This definition is not diagnostic and shifts the responsibility for imposter feelings away from the individual and towards the social situation or context in which they occur. ²⁴ Likewise, in their original study of IP, Clance and Imes theorised that the source of self‐doubt that supports the formation of imposter feelings arises from differences in what one is expected to achieve and what they can achieve, as viewed through the lens of societal expectations. Imposter feelings are further affirmed by a perceived differential in one's own self‐image with who society may expect a person in that role can be. ²

2. THEORETICAL FRAMEWORK

This study is informed by social identity theory and its application in medical education. ²⁵ We assume that social identity is constructed through one's self concept in relationship to membership in a particular social category, in this case the medical profession. Social identities (e.g., medical professional identity) can be constructed through social group interactions or collective identification that does not require personal relationships with members of the social group. ²⁶ Group categorisation involves developing cognitive structures based on characteristics of members of the group (e.g., knowledge and beliefs) that drive expectations about who a member of the group is (or is not). Medical students undergo self‐categorisation into groups, such as ‘physician’ or ‘medical student’, in which they compare who they are and who they are not to the perceived features of the group. Their group and individual identities are fluid and adapt to the context in which they are situated. ²⁵

Professional identity is a type of social identity, and like other social groups, medical professionals have a degree of control over their professional image (i.e., externally oriented persona). The concepts of professional identity and professional image can be described and are interrelated; what one identifies about their professional group is influenced by the way others see them, and professionals can project a perception of who or what they are as a group. ²⁷ One could therefore assert that identity and image are different but related constructs that emerge from internal and external sources. ²⁸ As such, self‐perception and the perceptions of others may influence one's seeming goodness of fit and professional identity formation (PIF) as a physician.

The early stages of identity formation may cause individuals to question their legitimacy and result in feelings of being an imposter. ²⁹ Incoming trainees are tasked with forming a new social identity as a medical student while at the same time developing the foundation for what will be their professional identity as a physician. ³⁰ The formation of a medical professional identity requires some negotiation or reconstruction of existing identities to form one that is consistent with the norms and values of the profession. ³¹ On the basis of this theoretical framework, we suggest that one source of imposter feelings comes from incongruencies between internal (self) and external (societal, professional) appraisals about the professional identity of physicians and who belongs (and who does not belong) to the profession. Identifying the sources of imposter feelings in medical students may assist educators in normalising the phenomenon and reducing the associated psychological distress. See Figure 1 for a representation of this framework.

FIGURE 1.

Theoretical framework of social identity and imposter feelings. Social identities are constructed through self‐categorisation into ‘in‐group’ and ‘out‐group’ characteristics. Professional image is one type of self‐categorisation that is influenced by external (society) and internal (the profession) sources. Imposter feelings may arise from incongruencies between internal (self) and external (societal, professional) appraisals about who belongs in the medical profession.

In order to identify sources of imposter feelings in medical students in more depth, we analysed prompted reflective essays that focused on the relationship between personal and professional identity at an early stage of development. Our overall goal was to gain better insight into the following research question, ‘What are the sources of imposter feelings in first‐year medical students?’

3. METHODS

3.1. Study participants

Students in the first year of medical school at Cleveland Clinic Lerner College of Medicine (CCLCM) of Case Western Reserve University and pre‐matriculating first‐year students at Indiana University School of Medicine (IUSM) were eligible to participate in this study. A total of 32 students are accepted into each cohort at CCLCM and receive a full scholarship in the 5‐year medical programme, which includes a master's level research thesis. Study participants from IUSM are a part of the Leadership and Academic Development Scholars (LEADS) programme, a cohort of up to 40 students who self‐identified as underrepresented in medicine (URiM) and/or having higher exposure to risk factors for diminished access to educational resources (e.g., low socioeconomic status, low Medical College Admission Test [MCAT] scores, first‐generation college student and low undergraduate grade point average [GPA]) who took part in an optional 4‐week pre‐matriculation programme. The LEADS programme defines URiM as racial and ethnic populations that are underrepresented relative to their numbers in the general population. The programme includes content in the basic sciences (e.g., anatomy, biochemistry and genetics), study skills workshops and professional development sessions.

Professional identity is a thread throughout the five‐year curriculum at CCLCM. Students take part in small‐group sessions and reflective exercises at specific time‐points throughout the curriculum. The small‐group session described below takes place at the beginning of the curriculum and serves as an introduction to PIF. The LEADS programme also has a curricular thread of PIF; as such, the first year PIF session was also incorporated into the curriculum at the inception of the pre‐matriculation programme.

3.2. Data collection

Students at both institutions took part in a formal, 2‐hour‐long small‐group session on PIF facilitated by the authors from both institutions. Prior to attending the PIF Session, students were asked to watch a 30‐minute pre‐recorded faculty lecture introducing professional identity and other theories of cognitive development. After watching the recording, students were asked to write and submit a 200–300‐word reflection using the following prompt: ‘Think back to the time when you decided to become a physician. As you made this decision, you must have had some idea of what a physician is. What was one part of your identity that you thought you would have to change in order to become a physician? Discuss the struggle you thought you would face as you aligned your identity to that of a physician’.

Completion of the reflection was optional, and students were also given the opportunity to opt out of having their reflection used in this study. Five cohorts of students from CCLCM completed reflections in August 2018 through 2023, within the first 2 months of matriculating as medical students. The reflection prompt was sent via email and responses were entered into a Research Electronic Data Capture (REDCap) database, a web‐based application designed to support data collection for research. Three cohorts of LEADS students completed the reflection in the middle of the pre‐matriculation programme in July 2021 through 2023. Reflections were collected using Canvas Learning Management System (Instructure, Salt Lake City, UT). All reflections were anonymised prior to data analysis, and no demographic information was collected to protect the anonymity of students in these small cohorts.

3.3. Data analysis

Included reflections were analysed inductively as there is no existing literature on sources of IP in medical students. The Framework Method was used as it allowed us to systematically analyse the data across institutions and cohorts. The method includes several iterative steps including familiarisation, development of a codebook, application of the codebook to the entire dataset, charting and interpretation. ³² All of the reflections were read by a team of analysts (M.E.K., J.N.B., R.M.F.), and reflections that contained experiences related to our theoretical framing of the sources of imposter feelings were included for further thematic analysis. Specifically, reflections were included if students described an incongruence between appraisals of themselves and the identity or role of a medical professional. Each analyst reviewed all reflections and independently decided if they should be included for further thematic analysis of imposter feelings. The analytic team had periodic meetings as new reflections were reviewed to reconcile included reflections. In the next phase, included reflections were coded by the same three analysts into broad themes of IP. The analysis team met repeatedly to reconcile differences and to update the codebook with more nuanced categories as new reflections were collected. At the end of the data collection period, a final round of code application was conducted in Dedoose, an online application for qualitative data analysis (M.E.K.). The analysis team met to interpret the data and organise the codes into themes. Finally, codes were charted across each theme and sub‐theme to evaluate the comparability of the sample and prevalence of codes across institutions and cohorts. The Institutional Review Board at Cleveland Clinic (#19‐974) and Indiana University (#15280) granted this study exempt status.

Several trustworthiness measures were employed to ensure the rigour and quality of the study. To be reflexive, we report all authors to be medical educators who view this work through a social constructivist paradigm. As such, we acknowledge there are multiple realities that are socially constructed and that individuals' experiences with imposter feelings are unique and subjective. As such, we do not seek to classify medical students as imposters but to explore the sources of imposter feelings described in student reflections. Frequent debriefing sessions with the team allowed for the researchers to discuss our assumptions about the research and how they may have influenced our interpretations of the data. Credibility was further established by the analysts (M.E.K., J.N.B., R.M.F.) formal training in and experience conducting qualitative research. Transferability was optimised by the use of the same prompt and analysis across several cohorts of students at two disparate institutions. Finally, based on our study question, sample specificity, rigorous methods and theoretical framework, we feel confident that our findings have sufficient information power. ³³

4. RESULTS

A total of 233 students (159 CCLCM, 74 IUSM) consented to their data being used in the study. Of those reflections, 121 met our inclusion criteria and were further analysed for sources of imposter feelings (Table 1). The average length of reflections was 241 words. Three primary themes were found in the reflections: (1) Comparing oneself to an idealised image of a medical student, (2) Comparing oneself to an image of an idealised physician and 3) Concerns about presentation of self to others. Each of the themes was present in every cohort of student reflections analysed. The themes included several sub‐themes that can be found in Table 2 and are described in more detail below.

TABLE 1.

Percentage of total and included reflections by institution.

	Total N	Included N	% Total included
CCLCM	159 (68%)	75 (42%)	62%
IUSM	74 (32%)	46 (62%)	38%
All	233	121 (52%)	100%

Abbreviations: CCLCM, Cleveland Clinic Lerner College of Medicine; IUSM, Indiana University School of Medicine.

TABLE 2.

Themes of imposter feelings in first‐year medical students.

Theme	Sub‐theme	Description
Comparing oneself with an ideal image of a medical student	All medical students are intelligent	Only the most intelligent get into medical school.
	Linear pre‐med pathway	Better medical students have linear pathways and backgrounds in the sciences.
Comparing oneself with an image of an idealised physician	Expected personality traits	Physicians are expected to be calm, confident, stern, extroverted and decisive rather than how students perceive themselves to be anxious, apprehensive, funny, introverted and uncertain.
	Role & status	Doubts as to place in medicine due to having a low socioeconomic background and being a member of minoritised group.
	Work–life integration	Students value work–life integration but doubt they will become a physician because their image of physicians is that they are people who have limited work–life balance.
Concerns about presentation of self to others	Impression management	Awareness of how others may perceive them in the role of a physician and making a conscious effort to hide certain aspects of self that seem incompatible with that of a physician's identity.
	Feelings of imposterism	Feelings of self‐doubt caused by not being able to perform as expected.

4.1. Comparing oneself with an ideal image of medical students

In their reflections, students shared concerns about not meeting the criteria for what they perceived to be the characteristics of ideal medical students. Some described how medical students were thought to be exceptionally intelligent and how this creates concerns about them being welcomed into the profession due to their perceived lack of knowledge. One student stated:

I just simply didn't think I would be able to cut it. I was a great student in undergrad, but I was for some reason under the impression that I was far too underqualified and not smart enough to get through the medical school application process, let alone medical school itself (I2, P231).

Other students described how comparisons of their pre‐medical experiences and pathways (e.g., abundant shadowing and volunteer experiences; coursework in the ‘hard’ sciences) compared with what they perceived ideal pre‐medical students to have had resulted in feelings of appearing inferior. As described by one student:

Every pre‐med I talked to seemed to be starting clubs, volunteering, and getting published with their research. As someone who usually had more than one job in college, achieving what they deemed ‘necessary’ felt unattainable. There is also a culture of overwork bordering on masochism that is popular among pre‐meds… (I1, P146).

For many, having been accepted into medical school was proof that their perceived limitations were incorrect.

4.2. Comparing oneself with an image of an idealised physician

4.2.1. Expected personality traits

In the majority of included essays, students described personality traits that they expected physicians to have and compared them with their own. Idealised personality traits of physicians came from personal experiences, either with their own doctors or through shadowing, or were derived from stereotypes often portrayed in the mass media. The most frequently cited contrasting personality trait was extroversion, where idealised physicians were described as being sociable, outgoing and assertive while the students thought of themselves as introverted, shy and restrained. Students often described how they felt and what they would need to learn in order to become more extroverted and successfully connect with their future patients. As stated by one student:

Having regarded myself as a shy and introverted person, I was worried that my personality would limit my ability to care and comfort my patients … I believe that I need to learn to act more outgoing and extroverted so that my patients would feel more comfortable opening up to me about their concerns (I1, P150).

Some students described how a history of anxiety and feelings of anxiousness about performing some aspects of the physician role increased their doubt. One student wrote:

I have always been an introvert and a bit anxious with public talking. However, I knew I had to change this in order to be a physician. A physician has to communicate effectively and incessantly with their patients, co‐workers, and other people to give the correct and efficient care to the patient. This was something that would always have me questioning myself about medicine as I doubted if I could get over my anxiety and that seeped into my perceived competence of being a physician overall (I2, P105).

Similarly, students described how they felt physicians embodied confidence, whereas they described how they had struggled with self‐confidence or were a hesitant person. One student wrote:

One part of my identity that I thought I would have to change in order to become a physician is confidence. I have struggled with low self‐esteem since I was a child, and even when I do well in things like sports or school, it's difficult for me to celebrate the victories and I tend to focus on the things I did wrong. When I decided I wanted to become a physician, part of me felt and still feels like I may struggle because physicians need to be decisive and confident in their decisions in handling the care of others (I1, P141).

Notably, students described how they lacked the self‐assurance to apply their knowledge, skills and abilities in medicine and to give others confidence in their abilities as well. For some, this was a barrier they had to overcome to ultimately decide on a career in medicine.

In addition to confidence, some students described the importance of physicians making critical executive decisions and expressed worry about their ability to overcome their indecisiveness throughout their training. One student described it this way:

My friends know that I am often gripped with self‐doubt and uncertainty. I am often indecisive, ruminating over all the pros and cons of potential outcomes that can ensue from my decision and actions… Knowing this about myself, I have been worried that my overthinking/indecisive temperament does not align well with my conception of what a doctor is and should be (I1, P083).

According to some students, one way that physicians are able to communicate assurance and develop relationships with their patients is through their demeanour. This was described in terms of physicians' being stern, serious and formal and how this was necessary due to the nature of medical care and the need to reduce patient suffering. For some, this stood in contrast to their fun‐loving/fun‐seeking personalities, and it was described as a challenge to reconcile this aspect of their personal identity with their developing professional identity. One student stated:

One aspect of my identity that I thought I would have to change is my joking, lighthearted nature. I had always found it difficult to balance my natural quick‐witted nature with the gravity of the situations that physicians often find themselves in. I have frequently had to battle with maintaining a professional air around myself when I'm shadowing because being seen as unprofessional is a label that it is very difficult to come back from (I2, P104).

4.2.2. Role and status

Several student essays discussed how aspects of their personal background made them question whether they could become a physician. Some students described how they had come from a family with lower socioeconomic status, and the concept of becoming a physician, and by proxy entering a high‐status profession, was foreign to them. One student wrote:

I admired [the physicians I saw on TV] but I never thought it was possible as I was not from a ‘rich home’.… I always doubted the possibility of becoming [a physician] as it had been ingrained in me (and was somewhat true in the community I grew up in) that becoming a physician was for people in families at the top of the social ladder (I1, P022).

Similarly, some students described the historical lack of diversity among physicians and considered being a minoritised person in medicine as a source of doubt regarding whether they could or should join the profession. Students described how their race, gender, sexual orientation and immigration status were barriers. One student described contending with their sexual orientation:

When I think back to my initial inclination and decision to become a physician, I very much thought of how I may need to conceal my sexuality as I began my path towards becoming a physician … Many of my experiences within the field of medicine in the past illustrated the field as mostly white, heteronormative, and male‐dominated, which initially furthered my struggle (I1, P047).

Another student described the impact of the lack of representation on their perceived ability to become a physician:

One thing that I struggled with is that I did not see many black physicians, nor did I have any that were in my family. At the age of 12 years old, I wondered if people who looked like me could pursue a career in medicine (I2, P130).

4.2.3. Work–Life integration

A common sub‐theme was the perception that physicians lacked the ability to integrate work and home life, often at the expense of their personal lives. Students described work–life integration as an important aspect of their identities that they wanted to maintain and the struggle they experienced at the thought of losing this balance in their pursuit of a career in medicine. One student stated:

As I embarked down the path of medicine I struggled (and still struggle) with the idea that pursuing medicine might demand the loss of many aspects of myself life outside of medicine. There do not seem to be clear answers about how much room being a physician leaves for other things, and whether making room for things outside of medicine necessarily comes at the expense of maximal competency or if a balance is within reach (I1, P137).

Some described wondering whether they would be a good enough medical student or physician if they spent time doing things outside of medicine.

4.3. Concerns about presentation of self to others

A few students described feeling the need to manage others' impressions of them to conform to what they thought others expected of medical students and other members of the medical profession. In the quote below, a student describes how they hide their true personality behind the ‘character’ of a doctor, as if in a theatrical performance:

From my little childhood experience with physicians, doctors were straightforward, cold, confident, and above all, an authority figure. When I think of myself, I would not choose some of these adjectives at first glance. I think I am warm, compassionate, and sometimes silly. I thought I would struggle to adopt these qualities as core features of my personality. Now I realize that when I am a physician, these ‘doctor qualities’ are only a part of my performance as a physician and are not innate or fixed. We all show different qualities and attributes in different situations. As humans, we put on a performance in professional environments, and for good reason. The patient‐physician interaction is homologous to a theatrical performance. There are costumes (e.g. white coat, hospital gown, scrubs, badges, shoes, and masks) and there are scenes (e.g. visits, rounds, and exams) (I1, P174).

Students described purposefully hiding aspects of their true selves that they considered out of alignment with the identity of a physician.

Finally, some students described feeling like an imposter when someone's expectations of them did not match what they felt internally. One student described an experience during a research rotation:

I feel that the label of medical student offers a set of expectations of what I should already know and already be able to do which may lead to this sort of treatment as equals. It was a little unexpected because, with imposter syndrome, I still struggle to accept the role I have been allowed to be a part of (I1, P069).

For other students, this was described as a general feeling of inadequacy and questioning whether they were deserving of being welcomed into the profession. One student commented:

When I started at [medical school], I had the same thoughts and once again had to dismiss the doubt that swirled around in my head. No matter how many people tell me I deserve to be here and that I am going to be a great doctor, I don't think it has sunk in that I will one day be someone people look up to (I1, P006).

5. DISCUSSION

As a lived experience for first‐year medical students, we found that the phenomenon of feeling like an imposter varied individually but was similarly present in the narratives of two diverse groups from different medical schools. In some ways, this is a surprising finding given the demographics of the two schools and the characteristics of the participants. One group was composed of students matriculating at a small private medical school with a class size of 32 receiving a full tuition scholarship; the other group was composed of pre‐matriculating students from traditionally marginalised communities and backgrounds about to enter a large public medical school with a class size of 366. The fact that the presence and prevalence of themes were found in both groups suggests that many of the drivers of IP may be similar across traditional demographic variables (e.g., race/ethnicity, socioeconomic status and gender) that have been used to stratify particular groups as more or less vulnerable to feelings of being an imposter. That said, several students self‐described being URiM in the Role and Status sub‐theme and described the impacts the lack of representation had on their feelings of belongingness in medicine. Thus, these results support other studies that suggest the structure and context of the educational environment plays a more significant role in URiM students' development of imposter feelings than demographics alone ³⁴ , ³⁵ , ³⁶ but that URiM students may additionally feel a decreased sense of belonging with their imposter feelings. ²³

Without experience to the contrary, the idealisation of novices' role and status is common in many occupations and professions; medicine is no exception. ²⁷ Our data suggest that feelings of being an imposter are both common among medical students in our samples, and these feelings exist across institutions and cohorts. In this regard, it may be useful to think of IP as a state that fluctuates with new experiences, roles and expectations across career stages rather than trait and therefore more normative than deviant or pathological. ³⁵ , ³⁷ The challenges associated with adapting professional identity around these times of transition can cause significant self‐doubt and feelings of imposterism. ³⁸ This is not to say that feelings of being an imposter, especially where they persist, cannot or do not lead to dysfunctional patterns of behaviour but rather to suggest that these feelings are also a normal and expectable result of comparing oneself with an ideal type/role model whether it is a peer, a fictional character on TV or an active member of the profession. Cultivation theory explains how TV shows influence the perception that personalities portrayed in fiction are similar to those in one's real life. ³⁹ Furthermore, socialisation can reinforce these conceptions when experiences match the mass media portrayal of the professional role. ⁴⁰ The degree to which images of the ideal physician arise from medical dramas in medical students could be an area of future research.

We note with interest the themes of work–life integration and what others think, that is, impression management, that were identified in the student reflections. It has been noted that up to 50% of practising physicians show one or more signs of burnout. ⁴¹ Whether the wish for better integration of work and life is generational, ⁴² the result of increasing public awareness ⁴³ or the medical school curriculum, the fact that it is on the minds of first‐year students is significant and may underscore a dissonance between what they observe in their teachers and mentors and what they want for themselves. The effects of this dissonance has yet to be fully explored but research has shown that students who value work–life integration are less likely to prefer surgery and more likely to prefer general practice. ⁴⁴ Our data demonstrate that the perceived culture of self‐sacrifice in medicine ⁴⁵ may be a source of doubt about students' perceived fit in the profession and their ability to be a good doctor if their lives do not completely revolve around medicine.

Similarly, the impression management sub‐theme contained multiple examples of students feeling that they have to hide qualities and characteristics of themselves that do not comport with what they believe is expected of them. This was particularly true of characteristics such as personality type and sexuality. Impression management refers to the process where individuals attempt to create, maintain or modify others' perceptions of themselves. There is a conscious effort on the part of the individual to reveal certain aspects of the self and to conceal others, as if acting on stage. ⁴⁶ Maintaining or blurring the discrepancy between desired and current image is one of the primary self‐presentational motives, ⁴⁷ and medical students have several motivations to engage in impression management as they are beginning to explore who they are in the context of medicine. ⁴⁸ However, a core characteristic of an imposter is someone who knowingly portrays themselves as something they are not. As such, medical educators should consider developing a culture to support PIF and reduce what can be the unintended consequences of impression management on learning, wellness and patient care. ⁴⁹

In summary, the results of this study illuminate a variety of circumstances in which first‐year medical students feel as though they are expected to be and act in a way that is contrary to who they or their personality characteristics are. Some students are remarkably insightful about the dilemmas these feelings pose and have functional ways of dealing with them. For others, feelings of being an imposter raise existential questions about whether medicine is the right career choice for them.

We acknowledge this study has strengths and limitations. To our knowledge, this study is the first to explore potential sources of imposter feelings in first year medical students. Given that our reflections are derived from two US midwestern medical institutions, some findings may not be representative of medical students as a whole, thus limiting the transferability of the results. From other literature, we can see that there are differences in student experiences between countries, ⁵⁰ indicating that national or regional differences are important to consider in studying IP. Gathering reflections from additional institutions would aid in the transferability of these imposter experiences. Furthermore, we did not collect demographic information from the students to protect their anonymity due to the relatively small sample size in each cohort. While some reflections self‐disclosed gender, racial/ethnic and socioeconomic status, it is likely that imposter feelings may vary across demographics due to medicine being historically dominated by white males of a majority religion, making entry challenging for many from minority and lower‐socioeconomic groups. ³¹ In addition, underrepresented racial and ethnic minority students experience minority status stressors that can lead to heightened feelings of not belonging ²³ , ³⁴ , ⁵¹ and must navigate predominantly white educational spaces while being seen as a perceived ‘other’. ⁵² Studies should investigate how inequity and other structural factors contribute to imposter feelings in minoritised groups. ¹⁸

We also recognise that our reflection prompt did not specifically ask participants about their imposter feelings or where they believed these feelings stem from. Without follow up addressing these questions, we are unable to determine with certainty that our interpretation accurately represents the participants' narratives, limiting the confirmability of our results. Future research should consider longitudinal analysis of how perceptions of ideal physicians develop and change over time.

6. CONCLUSION AND RECOMMENDATIONS

We began this study by asking, ‘What are the sources of imposter feelings in first‐year medical students?’ Based on responses from students beginning, or about to begin, their studies at two very different medical schools, we learned that across‐the‐board idealisation of the physician role, as well as individual and social expectations, plays an important role in creating feelings of being an imposter. Our theoretical framework and method of analysis also allowed us to better understand the lived experiences of the students and the fact that feelings of being an imposter occur along a continuum.

Taking into account both the strengths and limitations of our approach and supporting literature, we have three recommendations to offer that we feel may address the sources of imposter feelings described in this study (see Figure 2):

FIGURE 2.

Recommendations to reduce imposter feelings. Members of a profession have an influence on their professional image, and therefore, these recommendations seek to normalise imposter feelings through reflection with peers and own professional identity formation.

First, normalise feelings of being an imposter and highlight that this phenomenon is likely a state that fluctuates with new roles, expectations and experiences. Whether it occurs in the orientation to medical school or during courses on doctoring that occur in the first year, it is important to have conversations about feelings of being an imposter and let students know that they are expectable and normal. ²³ , ³⁷ Those responsible for mentoring, advising and coaching students should be trained to facilitate conversations about feeling like an imposter and support students in the developing positive beliefs in self and acceptance of feedback. ²¹ One practical approach is to have senior faculty share their own stories of feeling like an imposter at various stages in their careers (e.g., medical student, resident, fellow, and attending). We want to underscore how having diverse mentors, advisors and faculty members who represent the identities of students can further support learners who may not feel they belong in medicine during this stage in their career. ⁵³ , ⁵⁴ Medical schools can help to pair students with mentors who reflect parts of their identities. ⁵⁵

Second, encourage students to journal for themselves and also to engage in small group activities or peer support groups where it is safe to talk about feeling like an imposter. ²³ Narrative medicine sessions and writing prompts, such as the one we used in this study, are a good way to engage students. Sharing in pairs, quartets and in larger groups with permission of the storyteller can go a long way towards normalising feelings and building campus community around shared experiences. This strategy helps to promote a culture where learners, faculty and leaders feel comfortable sharing their vulnerabilities and uncertainties with each other. ²⁰ It may also be helpful for faculty reviewing narratives to attend to students' feelings expressed in the essays, particularly if they are demonstrating signs of sadness and hopelessness, to ensure steps are taken to promote the student's safety and emotional health.

Third, continue to create opportunities for students to share stories about their PIF across all years of training. A useful way for students to track their experiences is to create a folder in a portfolio that is dedicated to professional identity. In this way, students can refer back to the essay they wrote as they began medical school or residency and better understand their growth and development over time.

In summary, while the literature on IP demonstrates this phenomenon is relatively common among medical students, ⁸ , ⁹ , ¹⁰ , ¹¹ this study was the first to explore sources of imposter feelings in first‐year medical students. These results provide medical educators an opportunity to address imposter feelings and to use IP as a conceptual and practical framework for engaging students in sharing early experiences and normalising what is an expectable developmental step in the path to becoming a professional.

AUTHOR CONTRIBUTIONS

Megan E. Kruskie: Writing—original draft; writing—review and editing; methodology; formal analysis; investigation. Richard M. Frankel: Conceptualization; writing—original draft; writing—review and editing; methodology; project administration; formal analysis. J. Harry Isaacson: Conceptualization; writing—original draft; writing—review and editing; data curation. Neil Mehta: Conceptualization; writing—original draft; writing—review and editing; data curation. Jessica N. Byram: Conceptualization; writing—original draft; methodology; writing—review and editing; formal analysis; data curation; project administration; supervision; investigation.

CONFLICT OF INTEREST STATEMENT

The authors declare no conflict of interest.

ETHICS STATEMENT

The Institutional Review Board at Cleveland Clinic (#19‐974) and Indiana University (#15280) granted this study exempt status.

Kruskie ME, Frankel RM, Isaacson JH, Mehta N, Byram JN. Investigating feelings of imposterism in first‐year medical student narratives. Med Educ. 2025;59(3):318‐327. doi: 10.1111/medu.15533

DATA AVAILABILITY STATEMENT

Research data are not shared.