I think we need to talk about self-doubt in medicine, because it’s something that many of us feel at one time or other in our career.
I used to have a recurring dream that centred around a 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, I still hadn’t been successful. When I reflect back on this, and the many years it took for that dream to pass, I recognise that it was a manifestation of self-doubt in my abilities as a doctor. This happened during my time as a senior registrar and into my first couple of 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 may have been our first experience with adversity and when we start work, we're quickly exposed to situations that can lead to self-doubt and insecurity.
Failure and insecurities
Quality health care relies on high standards and attention to detail. When adverse events happen - as they inevitably do - doctors may be plagued by guilt and anxiety. Many doctors feel unable to share these struggles with colleagues and recurrent feelings of inadequacy contribute to burnout. Medical training neither 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. It’s also been found to be more common in women than men.
Why do we feel this way?
There are probably two main reasons behind this. Firstly, achievements are objective, but they feel relative. Intuitively, it’s easy to look back and see where your successes have been: completing school, university, internship and more. If you were forced to rank your level of success, you’d agree that it rates pretty highly in the bigger scheme of things. However, in reality, we’re much less sensitive to this absolute scale of excellence than we are our relative position within it. Insecurity comes from comparing yourself or magnifying the levels just above you. Just as you achieve one success, the next target snaps into view - and it seems so much further away. Insecurity comes from over-emphasising the rung of the ladder above you, rather than recognising the ladder you’ve already climbed.
Another reason for insecurities is the invisibility of this feeling. You aren’t aware of how many other people share it as well. Others seem so confident and secure and this reinforces your own doubts about your competence and illegitimacy. If you could look into the minds of many successful people, you would see that they too struggle with insecurity and concerns about their lack of merit. Confident people are highly visible, yet those who struggle with doubt keep their mouth shut about it.
Imposter syndrome
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”. Coming back to the ladder analogy, not only do the rungs above you seem unachievable - where you are currently feels untenable. You’ve reached this far through luck or because others incorrectly thought you did something impressive. You feel like you’re going to fall back down or off the ladder altogether.
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 - for example the shift from SHO into a registrar training position. Since transitions are a common feature of our medical lives, it’s not surprising that most doctors find self-doubt an intermittent rather than a continuous challenge. Another trigger may be a lack of feedback from supervisors. Generally, detailed feedback is reserved for those who are objectively struggling. Most 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 our training. Even though extra work might be needed in very 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 among peers 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 and normal self-doubt is among apparently self-assured doctors will provide some reassurance to those riding the ebb and flow of self-confidence. Once you realise it’s not something that affects only you, it’s a lot easier to get comfortable with those feelings. Much of the confidence and bravado you see in others is a thin veil covering their own doubts about themselves.
It can be hard, but if you try to consciously adjust your fixation away from the rung above you on the ladder of achievement. It’s not intuitive but taking time to reflect objectively how far you have traveled - and the difficulties you’ve overcome to reach where you are now.
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 about yourself can be reconciled by your supervisors honest opinion of how you are doing.
If an adverse incident or medical error happens, it doesn’t mean you are incompetent. We are all human, we all make mistakes and we learn from them. It‘s very important 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. A growth mindset as opposed to a fixed one is a strong protector, particularly in times of stress related to medical error.
Conversations with colleagues, supervisors and mentors about self-doubt may be an important aspect of coping. Medical educators 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 have any doubt about it, please do ask someone.
References
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Hu Y-Y, Fix ML, Hevelone ND, et al. Physicians’ needs in coping with emotional stressors: The case for peer support. Archives of Surgery. 2012;147:212-217.
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Legassie J, Zibrowski EM, Goldszmidt MA. Measuring resident well-being: Impostorism and burnout syndrome in residency. Journal of General Internal Medicine. 2008;23:1090- 1094.
"Rising to the Level of Your Incompetence": Exploring What Physicians' Self-Assessment of Their Performance Reveals About the Impact of the Imposter Syndrome in Medicine. Acad Med. 2017 Nov 7.
Sanford AA, Ross EM, Blake SJ, Cambiano RL. Finding courage and confirmation: Resisting impostor feelings through relationships with mentors, romantic partners, and other women in leadership. Advancing Women in Leadership. 2015;35:31.