I would like to talk about self-doubt in medicine, because it’s something we humans all feel at one time or other.
I used to have a recurring dream some years back. It centred around the sudden realisation that I still hadn’t passed my final Fellowship exam. I would wake up truly believing for a few moments that despite all I had done, it still wasn’t enough. When I reflect back on this, and the many years it took for that dream to pass, I see that it was a manifestation of self-doubt in my abilities as a doctor. This occurred during my time as a senior registrar and even into my first few years of being a consultant.
Medicine is an elite profession, and as doctors we don’t generally come from a long history of failure. We have excelled at school and many of us bringing a good dose of perfectionism to the mix. Medical school was often the first experience with adversity and once starting work we are exposed to gruelling environments. Situations that seem to intentionally seek out those who may have missed out on stress and self-doubt along the way.
Adverse events and insecurities
Quality health care relies on high standards and attention to detail. When adverse events occur - as they inevitably do - doctors may be plagued by guilt and anxiety. Many doctors feel unable to share these struggles with others and recurrent feelings of inadequacy can contribute to burnout. Medical training and practice neither sufficiently prepares us to confidently deal with our mistakes, nor supports us in sharing our insecurities. Successful doctors do find effective ways to navigate these struggles, but they are far from welcome conversations, with ourselves let alone others.
Research suggests that whilst some doctors' experience with failure and underperformance had tangible evidence of poor academic or patient outcomes, many more had recurrent feelings of self-doubt - i.e. perceptions that they were underperforming or failing. This isn’t limited to doctors early in their training, but includes seniors who experience these feelings despite clear evidence of academic and clinical success.
Although some doctors maintain healthy self-perceptions of competence with only rare instances of self-doubt, most exist along a spectrum that includes the imposter syndrome at the extreme: individuals who “despite their earned degrees, scholastic honours, high achievement on standardised tests, praise and professional recognition from colleagues and respected authorities…do not experience and internal sense of success”.
Studies suggest 30-40% of doctors in training feel like imposters at some point during their career. The imposter syndrome is a strong predictor of psychological distress, can make doctors feel unprepared for the next stage of their careers and adversely affect future job prospects.
Recurring not continuous
Most doctors experience self-doubt in situations where confidence is expected to be shown, but is not felt - new transitions or new professional challenges being a trigger. Since frequent transitions are a common feature of our medical lives, it’s not surprising that most doctors find self-doubt a recurring rather than continuous challenge. Another trigger may be a lack of feedback from supervisors. Generally, detailed feedback is reserved for those who are objectively struggling. Many doctors assume that absence of feedback can be taken to mean they’re doing well, but for some, lack of feedback creates doubts about competence and affects personal confidence.
Most of us at some time or other need for assistance or support during training. Even though development might be needed in specific areas, self-confidence across the board can take a hit when this happens. It’s very easy to lose perspective, yet rarely are these challenges insurmountable. They are certainly more common than you might realise.
Even outstanding performers can struggle and medical culture perpetuates the incorrect assumption that those who are doing well know they are doing well. Needing help doesn’t fit with the self-image of young doctors.
Solutions to self-doubt
Simply having an awareness of how common self-doubt is among apparently self-assured doctors will provide some reassurance to those riding the ebb and flow of self-confidence. We know that frequent transitions contribute to these phenomena and a supportive mentor can provide a degree of consistency and validation. Skills assessments generally include the learner’s self-appraisal of perceived skills across various domains. It’s important to be honest when completing these, so that perceptions and external validation may be reconciled.
The occurrence of a medical error does not mean you are incompetent. We are all human, we all make mistakes and we learn from them. It is imperative to debrief with a senior colleague after a clinical incident or near-miss so you can work through it in a positive, supported way, and keep appropriate perspective. I believe that a growth as opposed to a fixed mindset is a strong protector, particularly in times of stress related to medical error. I will write more about this soon.
Conversations with colleagues, supervisors and mentors about self-doubt may be an important aspect of coping. As medical educators, we need to be aware of the pervasiveness of self-doubt, lead conversations in this area and seek out trainees perceptions of their own skills - both in day to day practice as well as during times of assessment. Strategies to support doctors during times of transition through location and seniority would be particularly helpful.
The consequences of failing to support the unconsciously incompetent doctor are well recognised. What is less clear is the detrimental effect of failing to recognise and support the unconsciously competent among us. You’re not alone, we have all been there. You’re actually doing OK. And if you’re not sure about that, please do ask someone.
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