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Diversity & Inclusion Misdiagnosing Imposter Syndrome
Misdiagnosing Imposter Syndrome
By Ayomide Adeleye, MD; L. Tamara Wilson, MD; and Cassandra Bradby, MD, on behalf of the SAEM Academy for Diversity and Inclusion in Emergency Medicine
Increasing diversity and inclusion within medicine is an ongoing challenge that leading professional organizations have wrestled with for more than forty years. Recently, the Association of American Medical Colleges (AAMC), Society for Academic Emergency Medicine (SAEM), American College of Emergency Physicians (ACEP), and others have taken action to underscore efforts that promote diversity. However, the challenges Black people experience in navigating everyday interactions in health care and forging successful, longlasting careers are often overlooked. One such challenge is overcoming imposter syndrome, a term coined by psychologists Dr. Pauline Clance and Dr. Suzanne Imes, which describes a psychological occurrence in which individuals doubt their skills, talents, or accomplishments and has a persistent internalized fear of being exposed as a fraud, despite external evidence of their competence. While imposter syndrome was first conceptualized as occurring in high-achieving women, what is often overlooked is how imposter syndrome is also rooted in racism and other hierarchical systems. As this phenomenon becomes more widely recognized, the focus has been on how individuals can develop skills to overcome it. In the field of medicine, imposter syndrome is nothing new. A 2022 Stanford study found that U.S. physicians were at a 30% increased risk of reporting imposter syndrome compared to all other U.S. nonphysicians and at an 80% increased risk relative to people with a doctoral or professional degree in another field. Symptoms like emotional exhaustion and questioning one’s accomplishments were more common among women, young and unmarried physicians, as well as those who practice in an academic medical facility or within the Veterans Health Administration. Additionally, Black people are often more vulnerable to this feeling. Black physicians in medicine are unfortunately set up to feel imposter syndrome within the cultural context, environment, and institutional shortcomings of the medical system. When discussing imposter syndrome, the onus is often placed on the individual feeling like an imposter. In her 1978 paper, Dr. Clance describes the characteristics of individuals who experience “impostorism” — this includes traits such as feeling the need to be special, fear of failure,
denial of ability, and fear and guilt about success. In that same paper, which highlights individual behaviors and personality traits, individual and group psychotherapy is highly recommended to work through imposter syndrome. The value of talking about imposter syndrome amongst recognized peers should not be understated; however, progress can be halted if one is still immersed in an environment entrenched in bias. The individualization of imposter syndrome can inadvertently dismiss the systemic bias and cultural contexts that are essential to how it presents in Black scholars.
While the culture of medical institutions varies drastically, they greatly influence perceptions of imposter syndrome. Such perceptions present early in medical training with identity cues that signal who belongs and who does not. For example, individuals from marginalized groups only see images of white male figures heralded as intellects in the halls of their academic institutions. Many Black people can attest to being mistaken for ancillary hospital staff rather than recognized as a physician. Similarly, women physicians are often referred to as nurses due to individual inherent gender biases. For Black women, these intersectional identities compound their experiences of discrimination in the health care setting. Other ways institutions can influence perceptions of imposter syndrome include incivility rates, which are “low intensity” behaviors demonstrated by being mildly but consistently rude, discourteous, or impolite. These include being talked over, called the wrong name repeatedly, translated for, having ideas discounted, etc. When microaggressions like these occur, they should be treated as an opportunity to be addressed and corrected rather than ignored under the guise of antiquity, also known as “that’s just the way it has always been.” When people repeatedly deal with these transgressions, it’s no wonder that the feeling of being an imposter starts to creep up.
Bias in perceived intelligence and merit is another factor that can lead to Black people feeling fearful of their success — another symptom of imposter syndrome. The field of medicine is one that naturally attracts lifelong learners and is known to have rigorously high standards requiring a high level of conventional intelligence. Many assume that those who can navigate multiple standardized tests, complex academic training, and various clinical roadblocks are brilliant. Yet, the assumption of lower intelligence and lack of merit is often ascribed to Black physicians. Words like affirmative action and diversity quotas are thrown around to justify the questioning of their credentials. Rarely do racial majorities in medicine or men find themselves being questioned, but rather their voices are heralded and affirmed. Black physicians can find themselves feeling less heard and seen and can themselves start to deny or question their own abilities.
The harm caused by biased narratives and lack of representation aside, imposter syndrome is given a chance to grow when there are no opportunities to thrive in the environment. It is known that advancing within the medical field is met with more barriers for Black people, whether in the form of a lack of mentorship, sponsorship, or guidance. It can feel like a losing battle to be held to higher standards in order to be considered for advancement while simultaneously facing doubts and questions about merit. When Black scholars are promoted, they can find that these feelings grow stronger due to isolation and lack of representation. Following the summer of 2020, many Black scholars found themselves being promoted to higher positions to re-energize diversification. For many, these changes served to be Band-Aid solutions as they still found themselves the subject of discrimination, being silenced when speaking out, and being figureheads for committees without real authority or protected time and money to do the job effectively. It is time to stop misdiagnosing imposter syndrome. As described by social psychologist Jennifer Jordan, instead of presenting it imposter syndrome as a problem that arises within individuals, the focus must shift to the environment, context, and interactions that lead people to question their own worth. Institutions should first acknowledge imposter syndrome as a systemic issue, then begin dismantling it by deemphasizing the perceived inadequacies of the individual and simultaneously addressing systemic factors which create unfavorable environments for Black physicians. This can be accomplished by creating environments that decrease selfdoubt and reaffirm contributions from those traditionally prone to feeling like imposters. Pairing Black trainees and physicians with mentors who can help early career professionals navigate career challenges can help achieve this aim. From its inception, the profession of medicine was intended to exclude women and Black people. Institutions must be deliberate in undergoing acts that truly achieve inclusion. Organizations must redefine traditional notions of successful leadership models to avoid sexism, ableism, heterosexism, and other forms of discrimination. Creating an organizational culture that values the representation of Black physicians and intentionally seeks to place them in leadership roles with the requisite support and authority is imperative. It is also critical to reframe workplace values that are often rooted in racism, such as professionalism, to emphasize the unique and valuable characteristics of Black women physicians. Dismantling this heavily ingrained culture will take deliberate, intentional actions to avoid the continued misdiagnosing of imposter syndrome. ABOUT THE AUTHORS
Dr. Adeleye is a PGY-2 resident at the Baylor College of Medicine Emergency Medicine Residency. @md_mide
Dr. Wilson is a PGY-2 resident at Baylor College of Medicine Emergency Medicine Residency. @AskABlackDoc
Dr. Bradby is the program director at East Carolina University Emergency Medicine Residency and president-elect of SAEM’s Academy for Diversity and Inclusion in Emergency Medicine (ADIEM). @NotSoLilMD
About ADIEM
The Academy for Diversity & Inclusion in Emergency Medicine (ADIEM) works towards the goal of diversifying the physician workforce at all levels, eliminating disparities in health care and outcomes, and insuring that all emergency physicians are delivering culturally competent care. Membership in SAEM's academies and interest groups is free. To participate in one more groups: 1.) log into SAEM.org; 2.) click “My Participation” in the upper navigation bar; and 3) click “Update (+/-) Academies or Interest Groups.”
