Imposter!

It’s commonplace to the point of being trite: Med students, learning an absurd number of pathological entities in a relatively short length of time, erroneously (and repeatedly!) self-diagnose.

There are a number of reasons this might trail off after they become practicing docs. A diminishing susceptibility to scaring themselves. Increased exposure to patients who do, indeed, have these various conditions, and a more finely tuned awareness of what signs and symptoms are “real” versus imagined. Or, perhaps, one eventually runs out of new diagnoses to learn and “try on,” as it were.

Still, now and again something slips through the cracks, and, thus, I found myself flirting with a mid-career self-diagnosis: Imposter Syndrome. My susceptibility was increased, I suspect, in that I first stumbled across the condition on a website that was specifically talking about it in the setting of med school. (It is not, in fact, at all limited to med students.)

There’s plenty of stuff to read about Imposter Syndrome online, so I won’t rehash it in this little non-scholarly space. The upshot is that the afflicted comes to doubt himself -- Luck, rather than talent, skill, or effort, has been the reason for his or her achievements. Or, others have overestimated his or her accomplishments. Either way, there is a recurrent, if not constant, concern of being “found out” as a fraud who should not have gotten to where he or she is.

An aggressively selective environment, such as med school, is fertile ground for such “imposters.” Just to get in and stay afloat, let alone excel, one is constantly being tested and otherwise probed for deficiencies. Along the way, seeing others failing to make the cut, even if those peers seemed capable (perhaps even more so than oneself) … this is fertile ground for self-doubt.

Objective evidence that one maybe doesn’t deserve a spot in med school (less than stellar academic performance, applying in particularly competitive years, etc.) is even more fuel for the imposter-fire. And, long-term readers of this blog may remember that such factors were in play during my very own pre-medical life.

Again, there’s more than a little reading-material online of how folks can react to Imposter Syndrome, compensate for it, cope with it, etc. I should add that it’s not actually to be found in the DSM or ICD, so it’s more of a phenomenon than an actual disorder.

Still, since it came as something of a novelty to me when I stumbled across it, I thought some fellow over-achieving professionals in the reading audience might be glad to recognize it in themselves, if only to know “it’s not just you.” And, I wanted to share some ways I’ve found my thinking and behavior as a med student (and subsequent physician) impacted by it-not all of which are necessarily maladaptive.

An unwillingness to “stick one’s neck out” is at the core of a lot of it -- taking a stand on something, and risking that others will differ. That can be as simple as a med student offering an answer to a question posed on teaching rounds: If the answer turns out to be wrong, the student fears that a non-imposter would have gotten it right, and peers or mentors will be a step closer to recognizing him as an incompetent, if not a fraud.

Moving the calendar forward, it can be a practicing physician, shying away from making (or excluding) diagnoses. Radiologists might do a lot of hedging. “Cannot rule out” might be found in the majority of their reports, or they might find themselves unable to ever offer a single conclusive answer. It’s never simply appendicitis with these radiologists, but a finding could also be inflammatory bowel disease, malignancy, developmental variant, etc. Then, perhaps if they recognize they’re doing this too frequently, they might add “Correlate clinically” as if that takes the burden of specificity away and puts it back on the referrer. Or, they might skip the entire gesture of diagnosis, and reports might be purely descriptive, drawing no conclusions, with the impression simply saying, “See above.”

Aside from clinical work, an Imposter might have difficulty with routine quality assessment (QA). He or she might never want to “pull the trigger” on identifying someone else’s error, since doing so is taking a stand (sticking one’ neck out). The colleague, and QA committee, might, then, disagree with his stance, and again there’s the risk of being “found out” as not knowing things that a legitimate rad would.

When the Imposter is the focus of QA (that is, someone else says that he or she made a mistake), it can be a four-alarm fire of anxiety: Now, he or she is under direct scrutiny for (in)competence! They might react by fighting, tooth and nail, in defense of their performance…or at least to offer justifications as to why the error isn’t really as much of an error as it’s being made out to be. Perhaps, it is poor technical factors on the imaging, for instance, incomplete clinical history, or unavailable priors. Alternatively, the Imposter might size up the situation and decide that defending himself or herself will escalate the issue and bring even greater scrutiny, so he or she folds like a bad hand of cards.

I’d mentioned earlier that not all such compensatory behaviors are necessarily bad things, and it’s for that reason that, rather than trying for a radical personal transformation, I’ve chosen to embrace my inner Imposter. I’ve found it abrasive, and occasionally to clinical disadvantage, when I’ve encountered rads who pride themselves on making conclusive diagnoses near-100 percent of the time…and comfy with telling their peers, or even referring clinicians, that colleague-radiologist X was dead-wrong. Sometimes wrong, never in doubt, as the expression goes.

It’s probably a matter of personal style-your mileage may vary-but, I think I do better as a member of team when I err on the side of self-doubt and flexibility with conflicting opinions. I’m willing to accept a smidge of unreasonable anxiety about being “found out” if it serves as an internal governor for my ego.