Breaking the Cycle: A Qualitative Study of Factors That Mitigate Impostor Phenomenon Among Internal Medicine Residents

Impostor phenomenon (IP) is common among medical professionals, with up to 60% of physicians and medical trainees reporting some degree of perceived fraudulence related to their work.¹  Impostorism is associated with negative outcomes such as lower job satisfaction, less career planning, and lower career striving.^2,3  Health professions trainees, particularly those in medical, pharmacy, nursing, and dental programs, report severe impostor feelings,^1,4  as measured by the Clance Impostor Phenomenon Scale (CIPS).^5,6  IP is consequential and may be associated with low self-esteem,⁷  burnout,^8,9  anxiety,^9,10  depression,^8,11  and even suicide.^7,12 

It is unclear how to meaningfully prevent or mitigate IP.¹⁰  A recent scoping review identified only 17 studies (10 in health care settings) describing educational interventions for IP.¹³  Short, stand-alone workshops using reflective exercises and cognitive reframing to address negative thinking patterns were the most common interventions. No long-term outcomes were described.¹³  A recent randomized clinical trial of a 6-month group coaching intervention among female resident physicians focusing on burnout also demonstrated a statistically significant reduction in IP scores.¹⁴  This coaching program focused on participants’ internal thought processes and cognitive reframing. These interventions appropriately center on individual strategies to address maladaptive thoughts, as IP is understood to involve inaccurate self-assessments of one’s performance (despite evidence to the contrary) leading to self-doubt.

However, focusing only on internal factors may not represent the full picture of IP among medical trainees. Addressing only internal mitigators of IP may place an undue burden on individuals and may limit the success of interventions to address impostorism. IP was described first as a cycle by Clance in 1985,¹⁵  and later adapted by Sakulku and Alexander¹⁶  as an iterative process characterized by psychological distress and maladaptive behaviors driven by fear of being found out as an impostor. The IP cycle begins when confronted with an opportunity to be exposed as a fraud such as being faced with an achievement-related task.^16,17 

Graduate medical education (GME) residents frequently encounter achievement-related tasks and assessments, thus creating an environment conducive to the development of IP and perpetuation of the IP cycle.¹⁸  Little is known about the cyclical nature of impostor feelings among residents or the most important factors (internal and external) that may mitigate the cycle. Understanding the factors that exacerbate and alleviate IP may lead to the design of more effective methods to address impostorism. The purpose of this study is to explore the experience of IP among internal medicine (IM) residents and the factors that moderate their feelings of fraudulence.

Using a phenomenological approach, we sought to understand what factors mitigate IP based on the perceptions of IM residents. We approached the study from a constructivist paradigm, which holds that reality is influenced by social contexts and interactions and evolves over time.^19,20  This approach encourages informants to share personal stories using their own words. It also acknowledges the experiences and perspectives of the researchers and the impact of these on the work.

All IM residents (N=53) at the Johns Hopkins Bayview IM Residency Program in Baltimore, Maryland were emailed an invitation to participate in the study between May and June 2020. We conducted one-on-one in-depth semistructured telephone interviews with 28 (53%) IM residents who agreed to participate to learn about their experiences, elicit their feelings, and hear their thoughts about IP.

Individual interviews were performed due to the sensitive nature of this subject and potential negative feelings associated with impostorism. Informants were thanked for their participation with a $10 gift card to a local coffee shop.

The interview guide was developed using an iterative process based on published literature on IP and the authors’ own experiences in GME.^1,21-23  Interview questions focused on exploring an informant’s lived experience with feelings of fraudulence during residency training and how they cope with impostorism. Three pilot interviews were conducted to ensure clarity of questions, resulting in minor revisions to the final interview guide.

One author (A.C.) conducted all semistructured interviews, which each lasted approximately 35 minutes. Study informants provided verbal consent at the start of the session and were read a statement defining IP as per the interview guide (provided as online supplementary data). Limited demographic information including postgraduate year (PGY), age, gender, and underrepresented in medicine (UIM) status was collected prior to beginning the recorded interview.

Audio recordings of the interviews were transcribed verbatim by a professional transcription service (Ubiqus) and checked for accuracy by A.C. Each transcribed interview was uploaded to NVivo (QSR International) for data management and analysis.

Immediately following the interview, informants were emailed the 20-item CIPS to assess the prevalence and severity of IP among our informants (link provided in online supplementary data).^5,6,15  CIPS scores range between 0 and 100. The higher the total score, the more frequently an individual is affected by impostor feelings.^15,24  A score of 60 or above is consistent with frequent impostor feelings.^5,6,15  We used the scores to allow for comparison with other IP studies, and not to make inferences about individual study informants or comparisons by PGY.

We performed thematic analysis using an iterative process. Two authors (S.C.M, R.B.L.) independently identified meaningful segments of text on a subset of transcripts (5 each), resulting in a provisional coding template. A third author (S.M.W.) used the provisional template to review and code 4 transcripts not previously coded. A final coding template was developed after discussion to reach consensus on codes. It was then applied to all remaining transcripts by S.C.M. and R.B.L. The team met regularly (twice monthly for 4 months) to discuss meaningful concepts from the coded data, identify patterns and relationships, and name final themes and subthemes. The analysis was guided by regular referencing of the adapted IP cycle (Figure).^15,16  We considered the IP cycle described by Sakulku and Alexander,¹⁶  which focuses on how impostor feelings may be perpetuated when individuals encounter an achievement- or performance-related task or in response to a success or accomplishment. As noted, residency training involves multiple daily achievement-related tasks, such as presenting a critically ill patient in the intensive care unit, putting in a central line, or leading a team, which may drive feelings of impostorism. We adapted the cycle to simplify its presentation and to place performance-related tasks at the center as drivers of IP to highlight possible ways to mitigate IP. Descriptive statistics were used to summarize informant demographics. Mean CIPS scores were calculated.

At the time of the interviews, A.C. was a general IM medical education fellow who had completed IM residency training at another program. S.M. was a general IM medical education fellow and recent IM graduate, also from another residency program at the time of data analysis, who did not participate in the interview process. Both authors (R.B.L., S.M.W.) have extensive experience in medical education and research studies, as well as coaching and mentoring trainees in medical education. A.C. and S.C.M. regularly interacted with residents but did not have a role in resident evaluation. All authors acknowledge experiencing IP at various times in their training and careers.

A Johns Hopkins Medicine Institutional Review Board approved the study (IRB00243043).

Twenty-eight of 53 residents (53%) across all PGYs agreed to participate and completed interviews. Table 1 shows demographic characteristics and CIPS scores of informants. We present our findings, first based on components of the IP cycle, and then by whether factors mitigating IP were internal or external.

Informants provided examples of feelings of inadequacy, avoidance behaviors, distorted feedback, and attribution beliefs in relation to performance-focused tasks. Representative quotes describing the components of the IP cycle and triggers are listed in Table 2. Identifying these components helps to highlight the factors mitigating IP presented in the themes below.

Informants’ descriptions of their experiences dealing with IP suggest that some factors were driven by the resident and some were contextual or initiated by others. We present these as internal or external, each with individual themes in Table 3. Informants alluded to a combination of both internal and external factors driving their feelings of impostorism.

Informants describe internal factors that mitigate feelings of impostorism (Table 3). These are presented as the following themes: (1) reframing attribution beliefs with subthemes—gaining perspective and embracing uncertainty; (2) accepting feedback; and (3) acknowledging strengths. The themes reflect processes that may alleviate feelings of IP. Informants were able to shift their internal perceptions about their performance, such as recognizing success as a result of their own actions, as opposed to attributing it to luck. Gaining perspective by considering how much they had learned or accomplished and appreciating the nature of uncertainty in medicine contributed to informants reframing their attribution beliefs to more positive ones. Accepting feedback as genuine and supportive aided informants by helping them see their own growth and gain comfort with “not knowing.” Consequently, many informants described how adopting a growth mindset helped them to manage situations that had previously triggered and perpetuated impostor feelings.

This informant explains how acknowledging their strengths as a teacher helped to mitigate impostor feelings.

Some mitigators of impostorism involved support or contexts that were beyond the residents themselves. These themes include: (1) mentors, coaches, and role models; (2) formal opportunities to share IP experiences; and (3) growth-oriented learning environments. These external factors provided residents with outside support when faced with IP feelings through opportunities to acknowledge that IP is a shared experience among fellow residents and attendings and to challenge thought processes that perpetuate features of the IP cycle. Mentors, coaches, and role models who share their own experiences with IP, model self-doubt, and explicitly state that it is “okay not to know the answer” were mentioned as critical in creating supportive environments and lessening IP. Informants described structured opportunities wherein they could share their IP experiences with other residents as valuable programmatic supports. Informants highlight the importance of a growth-oriented learning environment, especially at times when they are most vulnerable to impostor feelings.

Our study identifies key factors that mitigate feelings of impostorism and which may interrupt the IP cycle among IM residents. These factors can be considered as internal and external to the individual experiencing IP. By focusing on the IP cycle, our findings highlight specific situations where IP may be more common or pronounced, demonstrate a connection between internal and external factors as mitigators, and importantly suggest opportunities to interrupt the IP cycle.

Studies of trainees in other specialties confirm the prevalence and severity of IP but do not explicitly describe its cyclical nature.^9,26,27  However, existing research does support an interplay of internal and external factors in IP among medical trainees and physicians. Intrapersonal factors such as having higher impersonal control motivation,^28,29  an orientation wherein an individual focuses on external factors as obstacles to goal attainment (an attribution belief), has been associated with higher CIPS scores among medical students.²⁸  Similarly, having a low tolerance for uncertainty is associated with more severe feelings of IP in surgeons.³⁰  External factors, such as learning environments that support the basic psychological needs of trainees and coaching programs may benefit those who experience IP.²⁶  Our study helps to further describe how internal and external factors contribute to IP among medicine residents and situates these factors in everyday experiences of residency training.

Understanding features of the IP cycle creates additional opportunities to address IP, which is often driven by exposure to achievement-related tasks that appear to emphasize performance over learning (for example, completing a certain number of procedures). One approach to transforming achievement-related tasks into true learning opportunities is to distill them into microskills. By breaking down each task into well-defined, challenging, yet achievable steps with clear expectations and immediate and supportive feedback,³¹  residents may approach these tasks with less fear and more of a growth mindset. Microskills may also help to rebalance trainee autonomy and supervisory support in a way that engenders growth orientation and support in the learning environment.³¹  Our findings provide insights into when and how to intervene in the cycle by understanding the nature of residents’ internal perceptions and which external factors are viewed as most effective.

Findings from our study may also help to better identify residents experiencing IP. For example, understanding how achievement-focused tasks trigger the IP cycle can alert educators who may wish to set clear expectations around performance, share their own IP experiences, and cultivate psychological safety through tolerance for failure and welcoming of questions. Our study also highlights some maladaptive thoughts and behaviors that may signal a resident is experiencing significant IP. IP should be explored when a resident is working excessive hours, as this may signal overpreparation as an avoidance behavior. Additionally, residents who do not ask for help or who do not regularly acknowledge learning gaps may be suffering from IP.

Our findings suggest that we can support residents in gaining perspective about the causes of their performance and recognizing uncertainty as ways to mitigate IP. These internal features may be strengthened by external efforts, such as having mentors who role model dealing with doubt, having structured programmatic opportunities to validate and discuss IP experiences, and experiencing growth-oriented learning environments.³²  Recent studies describing small-group discussions,³³  workshops,^34,35  and online group coaching,¹⁴  have suggested that increased awareness of IP may help to lessen its frequency among medical trainees. Several studies have suggested that environments supporting the psychological safety of trainees, such as those that encourage asking questions, can lessen the fear of failure associated with IP.^9,26,36-38 

There are potential limitations to this study. First, all residents were from a single IM program, which may limit the generalizability of our results. Second, most informants were women, suggesting a possible component of self-selection for participation. Still, this may reflect previous findings of women experiencing more frequent IP feelings compared to men.³⁹ 

Informants completed the CIPS following the interview. Participating in the interview may have influenced IP feelings; this may have affected their CIPS responses and score. Similarly, the timing of the interviews at the end of the academic year may have impacted CIPS scores. Some informants may have been experiencing increased IP at this transition time. Lastly, as with any qualitative study, there is potential for researcher bias.

This study identified internal and external factors that may mitigate the cyclical nature of impostorism among internal medicine residents.

The online supplementary data contains the interview guide used in the study and the Clance Impostor Phenomenon Scale.

Funding: Scott M. Wright, MD, is the Anne Gaines and G. Thomas Miller Professor of Medicine supported through the Johns Hopkins Center for Innovative Medicine, and he is the Mary & David Gallo Scholar for Hopkins’ Initiative to Humanize Medicine.

Conflict of interest: The authors declare they have no competing interests.

This work was previously presented at the Society of General Internal Medicine annual conference, Aurora, Colorado, USA, May 10-13, 2023, and at the International Association for Health Professions Education (AMEE) annual conference, Glasgow, UK, August 26-30, 2023.