This article was first published by MJA InsightPlus

IMPOSTER syndrome seems to be one of the better kept secrets in medicine. When I started my coaching practice in February 2018, I thought I’d be coaching doctors to find non-clinical careers to move into, just as I had done many years previously. I knew there was a need and had cofounded a Facebook support group for doctors interested in non-clinical careers which, at that time, had more than 1000 members.

So far so good. Doctors started coming to me indeed wanting to leave clinical medicine, but as it’s turned out, I’ve been helping most of them stay on in clinical work – much to my surprise and theirs.

It became apparent quite quickly that the reason many doctors were thinking of leaving clinical work was because they felt an almost overwhelming lack of confidence and associated anxiety, feeling like they weren’t cut out for the job. This despite awards, passing exams and assorted other positive feedback – classic imposter syndrome.

Struggling with lack of confidence as a junior doctor after returning from maternity leave was a large part of my own reason for leaving clinical medicine. Every day, I had such an overwhelming fear of making an error or that I would be exposed that I “ran away” into the non-clinical world.

Running away might have brought relief in some sense (and I have built a satisfying career), but it did nothing to address my own sense of failure that sat on my shoulder every day for many years and affected everything else I did. It took a lot of my own coaching until I felt like a real doctor and that I had earned the title. The thing is that, despite many years of working on personal development, I was still convinced I was the only one who didn’t feel confident.

Doctors just don’t talk about these things.

It came as a surprise to me that lack of confidence and feeling like an imposter were alive and well, not just in junior doctors or doctors returning from maternity leave as in my case. Doctors of all genders and ages who had earned their fellowship in any range of specialties were confessing to me their feelings of being an imposter. Not only that, they each seemed to think they were the only doctor struggling with confidence.

There are some limited information and data relating to imposter syndrome, or lack of confidence in doctors (herehere and here). Imposter syndrome, or imposter phenomenon as it is sometimes called, is thought to be driven by perfectionism and immersion in a culture of shame-based teaching. This, together with a high value placed on external bravado and a fear of expressing vulnerability, is a perfect breeding ground for cultivating imposter syndrome and hiding it.

Because there have only been a very small number of studies done on imposter syndrome and a few published personal reports, I can only really give anecdotal reports about what works in helping people turn this around. However, these anecdotes are not random. They are drawn from my own lived experience and grounded in principles of evidence-based coaching and the science of human behaviour. This approach aligns with suggestions for managing imposter syndrome published elsewhere (here and here).

My fundamental stance is that imposter syndrome – or doubting your own competence despite evidence to the contrary – is not illness. Not only is there no DSM diagnosis available for this, but the Dunning–Kruger effect shows that none of us are very good at judging our own competence. As their original article showed, a majority of people overestimate their competence in comparison to an objective measure, while a minority underestimate their competence, and of course that is anxiety-provoking.

It turns out that the people who underestimate their competence are actually the top performers. There’s a whole school of thought around why this happens that’s beyond the scope of this article, but it’s enough of a starting point to assume that competence (ie, knowledge and skills) is not the issue here. What it does suggest is that there is a need for a different way to approach judging our own competence and a reinterpretation of what it means to feel confident and what it even means to be a doctor.

Although this does sound like mind games, it does have practical ramifications, not least of which is that doctors move from being determined to leave to feeling they can stay in the profession with renewed enthusiasm and excitement.

First up is always a reality check: feelings are not facts. In fact, feeling incompetent is likely to indicate top performance.

Feeling the feelings and either rebutting them or not engaging them is a useful starting point for change, but not enough. If you want to feel competent and confident, you have to believe in yourself at some level. Faking it till you make it can be a great strategy if you feel you have what it takes to make it. If you don’t, then you might just be reinforcing the perception of being an imposter. That means finding a way to believe in your capacity.

It’s very important to get a handle on what you know you are good at, you need to know your strengths. You can get a sense of your strengths by undertaking a validated questionnaire. You can also begin to understand yourself better with reflective journaling focusing on what went well.

The medical profession is good at improvement by identifying and fixing flaws – think morbidity and mortality meetings. Looking for flaws is very useful in the process of diagnostics, for instance. However, it is much less useful in building a realistic sense of competence. To do that, you also need to know what went well in any given clinical encounter, why it went well and what your contribution was. However, our ability to notice what went well and why is atrophied through years of neglect and practising focusing on the negative.

Most doctors I talk with about their strengths say things such as even though they doubt their competence, they really care about their patients, they are good listeners and communicators, they have empathy. All of these strengths are absolutely core to building a good therapeutic relationship, which in turn is core to good medicine.

So, we start talking about practising medicine as a human-to-human interaction, which yes, is transactional, but a transaction that is delivered through something we might call love – for want of a better word. And a transaction engaged in with love moves beyond perfection, which is categorically impossible, into acceptance and compassion towards humanity, both to our patients and to ourselves. It allows for all types of emotions to be present that are part and parcel of the job and of being human and it allows us to move from the space of being fixers to healers. This is described beautifully by Rachel Naomi Remen:

“When I fix a person, I perceive them as broken, and their brokenness requires me to act. When I fix, I do not see the wholeness in the other person or trust the integrity of the life in them. When I serve, I see and trust that wholeness. It is what I am responding to and collaborating with.”

Growth mindset is another approach that has been used in medical education in helping doctors manage uncertainty and inevitable errors involved in medicine. In this context, adopting a growth mindset is about using error as a learning opportunity rather than as an excuse for self-flagellation. However, I tend to “power up” a growth mindset approach by blending it with goal theory and theories of self-regulation. In other words, helping people define for themselves what makes a good consultation or good practice.

This is not about going off-piste, it’s very much about staying within accepted practice. But the nuance here is about internalising what has been learned about what good practice “should” be. Internalising or, more correctly, identifying or introjecting these rules becomes self-motivating; it’s something you do more as an expression of self. It’s important, though, to develop a self-definition that is in some way measurable so that it becomes a yardstick to measure competence by. You can then set learning goals towards areas of self-identified gaps and measure progress. This is a much more nuanced way of applying a growth or learning mindset because it is targeted, contextual and trackable. And rather than building confidence in what you already know (a fixed mindset), you start to build confidence in your ability to learn and grow.

Managing imposter syndrome is ultimately about learning a new mindset that helps us embrace our vulnerability and imperfections and join with our patients on a journey of healing. It’s discovering what lies on the other side of fear.

Dr Jocelyn Lowinger has an Honours degree in Medicine (1994) and a Master of Science in Coaching Psychology (pending 2019). A former GP, Dr Lowinger now works in medical professional development including coaching health professionals. Visit www.coachgp.com.au