First, I want to say thank you to Lisa and Doug for inviting me to speak on this topic today. And I've enjoyed being at the course all weekend. I met a lot of you all yesterday in the hands-on. So I am an IBD specialist at Vanderbilt and have been – oh, thank you so much. And this topic is something that's been interesting. I learned about this when I was a fellow. So I'm very excited to give this talk because I didn't know about it until I was a fellow and it is a real thing. These are my disclosures. So y'all in this room – and I understand that there are some people that take a nontraditional path, but most of you have been through – let's add it up – 12 years of regular school, four years of college, four years of medical school, three years of internal medicine residency, three years of a gastroenterology fellowship. So that is 26 years. You've been a student or a trainee for 26 years of your life. During this time, you've had expectations that have been outlined for you. You've been evaluated, graded on these. You've moved to the next step. You've moved to the next step. You are soon going to be embarking on a new path. Your new path is going to be a path as a leader. And this is going to apply to you whether you take a job in academics, whether you take a job in a private practice. No matter what your career is going to be, you're going to shift to become a leader. At minimum, you're going to be a leader in your clinic, of your endoscopy team. You're going to be a leader amongst your peers and colleagues. You can choose to be a leader in national organizations such as ASGE. So you're going to be flipping a switch to where you're no longer going to be told expectations, but you're going to be the one actually doing things. And as a leader, you're going to be more responsible and take on lots of fun, exciting endeavors. And so during this 26 years you've been in training, you might have already experienced the imposter syndrome. But if not, in this flip, when you're becoming a leader, you probably will. So what is the imposter syndrome? So throughout this talk, I'm going to use these two terms interchangeably, imposter syndrome and imposter phenomenon. And that's because in the literature, how these are described, they're used interchangeably. So this, what it says, this is a phenomenon that was first described in the 1970s. So it's been described for over 40 years. Described by psychologists, Dr. Suzanne Imus and Dr. Pauline Rose Clance. They described this after they worked for a period of time with 150 female graduate students. So similar to y'all, lots of training, lots of objective evidence of accomplishment academically. But during working with these graduate students, they noticed that the majority of the students had an internal experience of intellectual phoniness. So this is a quote from their first paper, the women persist in believing they're really not bright, and that they have fooled anyone who thinks otherwise. Numerous achievements, which one might expect to provide ample objective evidence of superior intellectual functioning, do not appear to affect this imposter belief. And so this is, again, the first time this was described, so imposter phenomenon is that you all, I just explained, you've had 26 years of training at minimum, and you might go through times where you feel like you're not supposed to be in the room. Importantly, when we talk about imposter syndrome and imposter phenomenon, this is not a psychological diagnosis. Like I said, this has been described for over 40 years, and during that 40-year time frame, it's never become a psychological diagnosis. You should think of this as a reaction to situations. And one of the reasons I'm excited that ASU wanted us to talk about this today is because I want to normalize this. I'm going to show you how common it is, and I'm going to show you how we can beat it. But it's a reaction. If you have these feelings, it doesn't mean that you fulfill a DSM criteria, because there's no DSM criteria for this. There's not an ICD-10 code for this. So let's start with just a thought experiment, and I don't want any, nobody needs to raise their hands, but if you ever had a thought, what am I doing here? Do I deserve to be here? Did I get this opportunity because of my skills, my merits, or because of some other thing? Was I lucky? Or this is the one that hit home for me when I was a fellow, someone is going to realize at some point that I should not be here, that it's a mistake. If you've ever had any of these thoughts, and these are only four thoughts of a list of probably 50 that have been described in this vein of imposter phenomenon, then you've experienced this reaction. So this reaction is very common. I'm going to show you a couple studies. This is a study of medical students, looked at one medical student class, and surveyed them for if they had features of imposter syndrome. And in this study, importantly, about 75% of all respondents felt that they had imposter syndrome. Females, yes, were significantly associated with more than double, so about 49.4% of females had IS versus 23.7% of males. But again, importantly, collectively, we're talking about three-fourths of the whole medical school class experienced imposter syndrome. And then going a little bit further, why does this matter? Imposter syndrome has been significantly associated with burnout components of exhaustion, cynicism, emotional exhaustion, depersonalization. And then specifically for y'all, who are about to embarking, again, on a new phase of life, the fourth year of medical school was significantly associated with a higher rate of imposter syndrome. So we seem to have these reactions and experiences when we are changing points in our lives. Moving our scope a little bit broader, this is a review that was published that looked at 18 studies in healthcare trainees across the board, so medical students, medical residents, fellows. Prevalence was found, and obviously, depending on the study, lots of studies here, but prevalence 22% to 75%. Higher rates of imposter syndrome were seen in the female gender, in trainees with low self-esteem at baseline, and trainees who identified a poor institutional culture. So these things do matter. Higher rates of imposter syndrome were seen in trainees that cited good social support, that cited that they validate their successes, that practice positive affirmation practices, and that also practiced reflections. And overall, again, imposter syndrome was associated with higher rates of burnout. Y'all are just starting your careers. We want to try to educate you on things you can do to avoid burning out of them quickly. This is actually within gastroenterology. So this study was just published this year, and it was a survey of gastroenterologists. And to be fair, this was surveyed at a women's gastroenterologist conference, or a conference that was geared towards women, so that's why 97.5 identified as female in the survey. But in this survey of gastroenterologists, so this was mostly practicing gastroenterologists, some gastroenterology fellows, a couple of residents interested in gastroenterology, and one medical student at this conference, 88.2% reported experiencing imposter phenomenon or this phenomenon. And when you look at it a little bit closer on this figure to the left, you look at it by age. So if you were under 35, you were higher risk of experiencing this. If you're African-American, higher risk of experiencing this. And then what I think is really interesting and I think is important to pay attention to is at the bottom, if you're practicing gastroenterologists, scores were higher in the first five years of practice, which kind of makes sense a little bit, but interestingly, also higher in years 11 to 15. So kind of that early mid-career of gastroenterologists experience imposter syndrome. Do want to point out, this is not just a talk for women. So imposter syndrome really does affect a lot of different groups of people. This is a systematic review of 62 studies that was published, which included over 14,000 individuals. And obviously, there's a lot of heterogeneity within these studies, but the authors tried to focus on specific themes and factors. And so when they looked specifically at studies that had to do with gender, there were 33 studies included in this review, and there actually was no difference found in the race between women and men. So this whole, I think sometimes in the press, imposter syndrome is an issue that only happens to women. That's actually not true. This is going to happen or has potential to happen to anybody, no matter your gender. So just looking at age, there were only six studies included here, focused on age. This idea that perhaps imposter syndrome might happen when you're younger, but in this analysis, they found actually that age didn't really seem to matter. Ethnic groups, there was some differences that were seen. Imposter syndrome does seem to be more common among African-American, Asian-American, and Latino groups. And then comorbid conditions, and this is, again, I think getting to why this really is so important. Imposter syndrome is significantly correlated with depression, anxiety, low self-esteem, somatic symptoms, social dysfunction, and again, burnout when you look specifically in healthcare professionals. So what are the characteristics of imposter syndrome? So there are specific characteristics that have been looked at and described by clans when they first, as they've been studying this since the 70s. So one of the main things about imposter syndrome is the characteristics of perfectionism. So perfectionism is just the need to be the best. This starts in childhood. We all remember making the macaroni picture and being told it was perfect, and it gets put up on the fridge. Or you do, in class, in your kindergarten class, you do something great, told your person. Children are always rewarded for being the best. So the idea of being the best and being perfect starts when you're young. And what happens when people become full perfectionists, this standard just continues to get higher and higher. You must be perfect 100% of the time. The problem with this is that when perfection is the aim, everything is going to fall short, and success is actually not satisfying because you always actually feel that you fell short. This can increase in your work, it can increase overgeneralizing mistakes, and can increase non-constructive self-feedback, which is only going to play back into a feedback loop of negativity. Another feature is superheroism. So there's probably some superheroes in this room. So this is related to perfectionism and related to the need to be the best, but a little bit of a different spin. Superheroes tend to measure competence by how many tasks they can both juggle and excel in. So therefore, if you fall short of any of these roles, you feel shame and you feel disappointment. And even if you complete the juggling, you still can't be happy about it because you feel like you could have done more. And so you have an unrealistic view of how much is possible. You're switched on all the time. You can't enjoy any downtime in non-achievement-based activities. Fear of failure. So this is going to be a little bit more task-oriented. So this is when you experience anxiety, fear of shame or humiliation if you don't complete a task, or importantly, if you do worse than a peer on any task. So who remembers being a first-year fellow and learning endoscopy and the race to the SECUM? So great example of this. As you are scoping as a first-year fellow, I would imagine that the majority of you in this room, I know I felt it, you have anxiety about that goal. You have anxiety about it. And then you hear that your co-fellow got there in four minutes, and you're like, what? How did they do that? So it can be just you completing a task, or it can be you comparing yourself. And thus, you are an imposter. You should never be an endoscopist if you can't get to the SECUM as a first-year fellow in four minutes. We all know that that is a crazy thought, but you might have experienced that yourself. Denial of competence and capability. So this is when you discount your intelligence, experience, skills, and your natural talents. You relate any success to an external influence or random chance. You didn't work hard for this. You got lucky. This is one of the central, I think, definite things that happens when you experience imposter phenomenon is that you don't fall back on objective measures that you should be where you are, and you fall back on thinking that it was just luck. Just like we have fear of failure, you can have fear of success. So this is when you internalize and refuse to recognize success as succeeding could lead actually to higher expectations or increasing the workload, which you at baseline don't feel that you deserve. And so you might actually fear getting to the SECUM in four minutes, because then you're going to be expected to do that every time. And you think, oh, it was luck, the only time that you did that. So this brings us to what the imposter cycle is. I like these couple figures that we're going to go through. Most of the time, when someone experiences the imposter phenomenon, it does have to do with a specific project or a specific piece of work. And this can be something as common as a clinic day, just a full clinic day on your own, or something as uncommon as giving a talk at a national conference for the first time. So the work itself, it doesn't matter how significant it is or how special it might be, this can happen to you every week when you have clinic every week, or it can happen once a year when you give a talk. So when you're assigned that project or piece of work, you immediately have a little bit of anxiety, self-doubt, and worry about it. And then you do one of two things, you either over-prepare or you procrastinate. So if you over-prepare, you have this innate feeling that you don't deserve this task and you're not going to be able to do this, and you need to work harder than others to achieve the task. So you over-prepare. So in my clinic example, so I have clinic on Tuesdays, I take care of high-risk, moderate to severe inflammatory bowel disease. I'm going to see someone in the neighborhood of 25-ish patients that day. And if I'm over-preparing, I need to prepare for clinic because that's just my style. On average, it should take someone for that amount of patients probably an hour, maybe an hour and a half to kind of prepare for the clinic. But if I don't feel that I deserve to be there, and when I was starting out as an attending, I would take three hours the night before and go through every single lab, every single hospital, everything, and then I would complete the clinic because guess what, I'm qualified to do so. I graduated fellowship. I had great IBD training. I have great mentors that I can also call and ask questions about. Took care of all the patients appropriately. But I felt like a fraud because I was like, well, goodness, that took me three hours to prepare for that. Am I going to be able to do that every week? And I can't enjoy the success that I felt that I should have felt by being able to take care of patients in an appropriate way. And so I can't internalize my success. So guess what? The next Tuesday, same thing happens. So instead of the next Tuesday, me saying, I'm going to try to do this a little bit faster, a little more efficient, and go on, I can't internalize and overcome that, so I'm going to keep over-preparing. The other option in my example is to procrastinate. So I have clinic on Tuesday. I feel like a fraud, so I'm going to just pretend like it's not going to happen. And then Tuesday comes, and I am pre-charging on all my patients right before I walk in the room, because I was scared to pre-charge on them before. And it's hurried, last minute, feels really crazy. I finish my day. Takes me a little bit longer, but I finish it. But I feel like a fraud, because I just feel like it was all jumbled together, and I didn't really know what I was doing. So I still can't notice for myself that I actually achieved the goal. I took care of the patients appropriately. And I can't internalize that. So whether you over-prepare or you procrastinate, actually, most of the time in imposter syndrome, you still complete the task. You actually do the task successfully. It's just that you can't actually take credit for it. Any positive feedback you have, you end up pushing away. And then when a task, any task, or that same task comes up again, you go through the same cycle. OK, so that's what imposter syndrome is. Now we're going to spend the next couple minutes talking about what we do about it. So I'm going to take you all through all of these different ways to, things that you can do internally, things that you can do today, if this is something that you experience. We're going to talk about sponsorship. We're going to talk about increasing awareness, celebrating success, reframing failure, breaking habits, and then finally, getting help. And I think it's important to realize, again, there are some of you that might not ever experience this. And I hope that that's the case for you. But I think it's something that you might expect to experience at some point. You might not experience one time when you have that big ticket item, when you are giving that talk at a national conference, or that first time that you're having your first scope day. You might experience this once. But there are some of you that might experience this on a more regular basis. And that we'll talk about at the end with the getting help. So first thing is sponsorship and increasing awareness. Increasing awareness is extremely important for this phenomenon. Like I said at the beginning of this talk, I didn't know what this was. My division had a talk on this when I was a GI fellow. And I was like, oh my goodness, this really resonates with me. This is definitely something I experienced. And when you put a name to something, as we all know, just applies with most things. You put a name to it, it makes it less scary. You can identify it. And then you can start to expect it, or project it, or fight against it. And so awareness needs to happen on multiple levels. So our national societies, so ASGE, ACG, have done a really good job of putting this out there in the past couple of years. And like I said, I showed you a paper that's been published earlier this year on this. But even on a personal level, it's important to just share your experiences with your network. Just an anecdote from even this weekend, I was meeting with one of the faculty members here. We trained together, but I hadn't seen her in seven, eight years. We were having this conversation in the Uber on the way to dinner about life. And I mentioned that I got a promotion at work about a year ago. And first thing I did was say, oh, but I'm not like the guy I took over for. He was a big researcher. I'm not a big researcher. I don't know what they were thinking. And she had to stop me. And she had to say, Robin, you deserve this. You know that you do. And she was correct. So like I said, I just did this to myself on Friday. So you have to share your experiences with your network, and your network can help you with that. What is your network? You have to build, you have friends, your family, your mentors. You had a great talk on mentorship by Dr. Adler just a little bit ago. And then I think what's very important for imposter syndrome and imposter phenomenon is allies and sponsors. So what are allies and sponsors? Sponsors are not mentors. Allies and sponsors are not mentors. Mentors help you define the doors that you want to walk through. Sponsors are the people that open the doors. Sponsors are going to be people that you probably don't meet with actually on a regular basis. A lot of them are going to have higher seats at the table. But they are the ones that if you express interest and if they can see you, are going to be able to give you opportunities that you deserve. And as you get more of opportunities, you can work on the fact that you deserve to be there and you have a seat at the table. So what can allies do to help? So this is a slide from another paper that was published on imposter syndrome in 2023 in the Red Journal. So allies can recommend you for talks, can offer to include your name on research papers, can encourage you to pursue further leadership training. If you're in academics, sponsors are the people that can support your promotion. Sponsors, of course, can listen to you, can include you into things, can nominate you. As we all know, networking is huge. You've learned a lot about networking, hopefully had some opportunities to network here. Sponsors can do that for you. They can nominate you for leadership positions, for a moderator role at a conference. They can do all these things for you. It's also important, especially if you suffer from imposter syndrome, to work on flexing this skill. You have to become a self-promoter. So every single person in this room is qualified to be here. Every single person in this room has their own wonderful things to bring to a table. You have to let people know what that is. So a question for you. In the last three months, and you're going to say this, I love it. In the last three months, can you think about one or two successful tasks that you completed? Did you claim credit for them? If the answer to that is no, you need to think about the next time you have a task to complete, how can you claim credit for that? So it can be as simple as, I'm giving this talk today. We talked about this yesterday. I'm going to put it on my CD. I'm going to claim credit for that. It can be as simple as, I finished my statistical analysis on my research. I need to meet with my research mentor again, and we need to get our next step of our project going. People with imposter syndrome are less likely to do this, and so that's why you have to flex this skill. So you have to define your own definition of success. If you find a sponsor, you have to put yourself out there and ask for specific opportunities. Nobody is going to give you anything that you do not ask for. You have to ask. And then when you get to the point when you can be a sponsor, you can pay it forward. So that brings us to talking about success, and this, I think, is really important. So we have to define and celebrate our own successes. You have to define success for what it means to you. We heard a lot yesterday about when you're applying for jobs, you have to have your goal in mind. This is somewhat on the same vein. You have to decide what, for you to be successful, what that looks like. You have to be deliberate and acknowledge accomplishments. And if this is difficult for you, I'm going to talk about some gratitude exercises you can do to try to focus on what you have accomplished. So when we think about defining success, traditional success, what we've talked about a lot this conference, too, money and position. That is what everybody thinks success is all about. I'm actually here to tell you that it's actually about, I mean, I think everybody has a different opinion on this, of course, but there's other ways that you can measure success. Think about the actual experience of your work. Enjoying your co-workers, enjoying your patients, having control of your time. I'll tell you for me personally, that's my success, is having control of my time. Believing work makes a positive difference, collaboration, balance. Some people, a four-day workweek might be success for them. It's going to be actually different for you, depending on what your goal is for your career. We and organizations struggle with this. So when you're looking for jobs, again, they're going to tell you how much they're going to pay you and what your position is going to be in that job. Because everybody operates on the presumption that a high salary and a good position means success. But when you're thinking about this, you have to think outside the box a little bit. If money and position are what it is for you, that's great. And that's valid, because that's the most common. But it might not be that. So if you, when I asked that question, if you said, think about a task, a success that you've had in the past three months, if nothing came to mind for you, that's OK. You've got to start training yourself to recognize a lot of the work you're doing are tasks that are successful. And so some of the ways to do this, easy, easy things you can do are gratitude exercises. So I've just listed a couple here. Gratitude exercises are things that you do that are actually going to, in turn, help you focus on your successes and accomplishments. So journaling is an easy one. So kind of writing down, periodic journaling, you can do it once a day. You can do it once a week. Writing down things that you're thankful for. And then when you look back on them, you can translate that to a task that you completed. Gratitude jar, this is a similar idea to journaling. You write on a piece of paper three things you're thankful for in a day, or one thing in a day. And then when you're struggling with if you feel successful or not, or if you're struggling with an imposter phenomenon type feeling, you can go back into the jar very quickly. And you yourself have proven yourself wrong because you have it there. There's another thing called a gratitude countdown. This is something you would most likely do with a colleague or a family member. And very, very quickly, name 10 things that you're thankful for. And as you name those things, of course, you're probably going to name some personal things and things like that. But there are going to be some work success things that come in there. And then you can start to recognize within yourself that you are doing things that you're being successful at and that you should be proud of. Next thing we're going to talk about is reframing failure and breaking habits. So again, interestingly, most people that experience imposter phenomenon, they actually are successful in complete things. But we all are going to fail. And people with imposter phenomenon, when they fail, it tends to be a bigger setback than people that don't experience imposter phenomenon. But I think you have to, have to, have to, if this is something you struggle with, you have to reframe failure. Failure is a universal experience. If you've never failed, you've just blocked it out of your mind. Everybody's failed. It's a natural part of the learning process. And it's actually required for personal growth. But rather than interpreting failure as a sign of incompetence, you have to, when you fail, you have to reframe it as an opportunity and a stepping stone for future success. So how do we do that? So you have to acknowledge the failure. So I didn't make it to the SECAM. That's going to justify it. It's not, I am a failure as an endoscopist. But it's, I didn't make it to the SECAM this time. You have to avoid blaming yourself or others. And this is pretty important because you can get in a bad track here, blaming your tech or blaming Olympus for their equipment, whatever it happens to be. But again, you don't want to blame yourself. You don't blame others. And you are not the failure. The task failed. You don't want to blame the patient either in my specific scenario. And then you have to choose to actively learn from the failure. So you're not blaming yourself, but you have to analyze what happened. Was looping too much in the sigmoid. I did not reduce when I should have. I didn't ask for pressure appropriately. Those are things, I'm not blaming myself, but I'm analyzing the steps that I took during the case that might have not led to success. And then once you objectify it and analyze it, that will allow you. And what you have to make a conscious decision to do is actually to keep moving forward. Breaking habits. So these are some very common habits that a lot of highly professional individuals have, and specifically people that do suffer from imposter phenomenon. Perfection trap. We talked about this earlier. You're a perfectionist. The disease to please, always making sure that everything is great with everybody. Minimizing. Ruminating. This has to do mostly with ruminating on failures. Reluctance to claim achievements. Expecting others to spontaneously notice and reward your contributions. Failing to enlist allies. And then putting your job before your career. So you have to break all of these habits. And how do we do that? You have to acknowledge your feelings. You have to consciously be aware of negative self-feedback. And you have to challenge that on yourself. You have to focus on the facts and on the objective measures that got you to the place that you are. Practice self-compassion. Everybody in this room is probably pretty hard on themselves. We're all very hard on ourselves. You have to be compassionate with yourself. Seeking support, again, in that support network can be family and friends, all the way up to mentors and colleagues. And then it's important to push yourself to just take on new challenges. Habits are very difficult to break. Behavior change is hard. The NIH has done a lot of work on this. Nobody likes to be told what to do. You don't like to be told you're not doing this correctly. Do it this way. You've got to figure it out on your own. So that's why behavior change is so difficult. How I personally try to break habits, and I learned this from professional coaching, which I'll talk about in a minute, I start with one defined goal for change. Identify three to five small action steps to get there. I acknowledge for myself that I'm going to fail and that's going to be OK. And I actually make sure that when I do fail, I write that down and kind of go forward from it. And then when I do have success with my steps, I celebrate that. And I do that with my support system. So that brings us to the last part is getting help. So again, I want to normalize imposter phenomenon because this is not a psychological syndrome, but it certainly can have a significant impact. I think one of the best things for imposter syndrome is to have a professional coach. So just like a mentor is different than a sponsor, a coach, a professional coach, is very different, serves a very different role. Coaches are oftentimes not necessarily in medicine, but they are independent parties and non-biased parties that can come in and can help you get to your success. So whatever that goal of success is for you, they can help you be efficient. They can help you figure out ways to move forward. And when you suffer from imposter phenomenon, they can be very helpful in calling you out on the negative feedback and goal-seeking and pushing you forward. Taking a step further, sometimes counseling is needed for imposter phenomenon. So if you do have imposter phenomenon with clinic every week, it's not a terrible idea to take it a step further and consider counseling or CBT or psychotherapy. And then taking it back to some of the studies I showed you at the beginning of this talk, sometimes imposter syndrome is going to be related to depression and to anxiety. And so while imposter syndrome itself is not going to need actual medication, sometimes you're experiencing that and you need to dive into that and get that treated. And it's going to make you a better person. So all that to say, if you wake back up, this is a common thing and really want to normalize it. Some studies show it happens more in women, but really across the board, I think it's going to happen, has potential to happen to each one of you. It's a feeling. It's not a psychiatric diagnosis. And to overcome it, there are multiple things that you can do that you can do personally. You can do it. Nobody else has to know about it. And importantly, you've got to seek help if you need it. And that's it.

imposter syndrome

medical professionals

psychological phenomenon

self-promotion

supportive networks

professional coaching