COMMENTARY

'Don't Screw Anything Up': The Epidemic of Imposter Syndrome

Ravi B. Parikh, MD, MPP

Disclosures

November 07, 2019

As I walked my first patient back to the exam room, my only thought was, God, don't let me screw anything up.

It was my first clinic after oncology fellowship, at my local VA medical center. Every aspect of my schooling and clinical training had prepared me for this moment, seeing patients independently and helping them navigate what was probably the most important health issue of their lives: cancer. Nights studying for exams. Even longer nights caring for patients in the ICU. Countless hours spent discussing both scientific and spiritual concerns with patients in exam rooms. It had all led up to this.

Thankfully, my medical director started me off easy—only one visit, a follow-up for a man with advanced prostate cancer. His PSA was well controlled on enzalutamide and he was tolerating the medication well. No scan review and no need for a scan before his next appointment. We spent most of the visit talking about his family and the issue of having to wait for his medication to arrive in the mail. After speaking to one of the pharmacists, I asked him to go to the in-house pharmacy window to pick up the medication. He'd return next month for another toxicity check and to receive his androgen deprivation therapy shot.

How am I ever going to be as good a doctor as this guy?

As I walked out of my very light clinic day, I found it ironic that after years of poring over books and listening to lectures about clinical science, my first clinical decision as an attending physician was determining where to send a medication.

I also knew that my clinical encounters would only grow more challenging. And I questioned whether I was up for the challenge.

Imposter Syndrome

There has been a lot of discussion in the medical literature recently about imposter syndrome, the underestimation of one's abilities and a perceived lack of success despite evidence to suggest otherwise. Imposter syndrome is particularly well documented among medical trainees and female physicians and is associated with high levels of burnout in medicine. Physicians who are subject to imposter syndrome may internalize criticism and externalize success. Imposter syndrome may be particularly high among early-career physicians like myself, who lack sufficient positive patient experiences to provide internal validation and who are surrounded by others who are eminently successful.

This was perfectly illustrated to me as I walked out of my clinic that day. I ran into one of my mentors, a more senior oncologist. He had already begun his clinic day and was well into his sixth patient of the morning, maintaining a brisk pace in his schedule. His patients loved him, and as he passed them in the waiting room he always had a brief quip or comment about each of them that indicated how much he knew and cared about them.

As I walked out, I thought to myself, How am I ever going to be as good a doctor as this guy?

A False Premise

As I've grown more comfortable with my role as an attending, I've realized that a huge component of imposter syndrome comes from my own internal psychology. Despite having ample resources (eg, a nurse practitioner, nurse navigator, scheduling staff) and a relatively light clinical load (at least, compared with the average private-practice oncologist), it is my own internal expectations that cause the imposter syndrome. I think there are a few important things for early-career oncologists to realize about imposter syndrome and why it's more fiction than fact.

Patients Come Back

As fellows, most of us see new patients almost exclusively. Because of the rotating nature of our clinical interactions and the need to devote most of our clinic time to preparing complicated new patient visits, we see relatively few return or follow-up visits. Managing routine chemotherapy or immunotherapy toxicities is actually relatively rare for us, given that the majority of our time is working up new patients. Because of this, I felt the need to "do everything"—explaining and consenting for chemotherapy, detailing side effects, ordering as-needed medications, and sometimes documenting end-of-life wishes —during a new patient visit.

There's no need to tick off every box at an appointment.

During my first new patient consult as an attending for a man with biochemically recurrent prostate cancer, however, I quickly realized that "doing everything" at the first visit wasn't sustainable—or even safe. It took most of the appointment just to confirm primary data and identify the patient's wishes. By the time we had discussed and mutually agreed on a treatment plan, I was 10 minutes late for my next visit. There was no way I could take care of informed consent, prescribing antiemetics, and the 10 other things that would need to happen before he started therapy. We resolved to take care of these things at another visit the following week. But after that first visit, I felt guilty and inadequate for leaving my patient with unanswered questions.

Only now that I'm following patients longitudinally have I realized that patience is a virtue. There's no need to tick off every box at an appointment; the good news is that, barring catastrophe, we always have the chance to see patients later. Delaying therapy a week or keeping things simple during the initial consultation isn't always the worst thing in the world.

Relying on Others Doesn't End

My final year of fellowship was fantastic: I had the opportunity to make independent decisions while still running most things by my mentors. While my first year of fellowship was spent learning general principles of oncology, my second year was spent delving into two disease areas—thoracic and genitourinary cancers—and learning the intricacies of practice-changing trials and the practical issues of administering therapies. It felt good to focus on two cancers that I could imagine spending the rest of my life treating.

Tumor boards have become my friend.

When I imagined my transition into a faculty position, I always pictured myself emerging fully formed from the protective cocoon of fellowship. Instead, it felt more like "sink or swim"—there would be no reliance on senior mentors or lectures. I would have to make decisions on my own using whatever knowledge I had.

This false notion of complete aloneness contributed to the imposter syndrome on my first day of clinic as an attending. Where was my attending to confirm my intuitions?

I happened to run into one of my old VA preceptors after my first clinic. Even though my case was pretty straightforward, I brought it up casually to him, mentioning what my plan was. Casually, I asked, "Is that what you would have done here?" He said, "Yes."

I've slowly realized that, even as a junior attending, it is completely okay, and maybe even expected, to run cases by old mentors. Tumor boards have also become my friend: Even though most tumor boards are typically reserved for complex cases, I've often brought up relatively simple cases when time allows, to confirm my intuitions. Rather than seeming annoyed by this, all of the members of these tumor boards have appreciated the routine cases, even using them as teaching opportunities for residents and fellows.

The imposter syndrome as an attending is mitigated when you realize that you're never truly alone.

Why Does Imposter Syndrome Exist?

As my imposter syndrome has begun to diminish, I've often wondered how the "old school" oncologists managed this transition from training to attending. If imposter syndrome exists for me, what must the community oncologist feel, without being able to rely on other oncologists in the room or regular tumor boards? Who am I to complain?

I have quickly realized that it is often the system we are put into that reinforces imposter syndrome. For academic oncologists in particular, there are several factors that contribute.

First, as an academic oncologist with a disease specialty, I often think of myself as the "oncologist of last resort," the person expected to know it all when I get the occasional referral from a community oncologist. But even as an attending there is still a learning period, and it is during this learning period that imposter syndrome is most manifest.

Second, because the clinical volume is so much higher for community oncologists compared with academic oncologists, community oncologists may take less time to step into their comfort zone. As a result, imposter syndrome may pass much more quickly for the community oncologist.

Finally, and perhaps most important, now that I have been thrust into my faculty position, I have also assumed responsibilities to lead research studies and teach residents and fellows. Most days, I spend time in all of these domains (clinical, research, leadership, and teaching). There is a learning curve to all of this, and often my mentors or supervisors are different for each. For many academic oncologists, or those who have roles beyond clinical oncology, imposter syndrome exists in all of these areas. Not to mention the imposter syndrome that comes with being a first-time parent or buying your first house or car.

Acceptance

In the end, I've learned to accept that my first year on faculty—maybe even my first 2, 3, or 4 years—will be a learning process where I will often feel that I could have done better. This frequently comes up when I am surrounded by fantastic clinical, research, leadership, and family role models. But I'm slowly realizing that many in my position feel the same imposter syndrome, and it's likely that many who are more senior to me still experience it now and then. Rather than feeling bad or inadequate, I think that it's these learning opportunities that make it so intellectually stimulating to be an oncologist. As long as I don't let the imposter syndrome get in the way of treating patients—or as long as I am honest with patients about what I don't know or can't do—then perhaps my imposter syndrome isn't such a bad thing. If I ever feel completely comfortable with my day's work, if I stop questioning why I made the decisions that I did, then it probably means that I am ready for a new challenge.

Ravi B. Parikh, MD, MPP, is an instructor in medical ethics and health policy at the University of Pennsylvania, and staff physician at the Corporal Michael J. Crescenz VA Medical Center.

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