In Response to “Persistent Impostor Phenomenon Is Associated With Distress in Medical Students”

We read with great interest the recent article published in your journal by Rosenthal et al,1 which discusses the imposter phenomenon (IP) experienced by many health care professionals in training, but which is particularly common in medical students.2 As a group of female graduate medical students studying medicine as our second degree on an accelerated curriculum, we were alarmed to read that IP occurs in nearly half of all female medical students,3 and we too share this experience. We agree with many comments made by the authors,1 and would like to share our experiences and thoughts in an attempt to draw more awareness to this debilitating but malleable personality construct.

As a group of consistent high achievers, in keeping with the student group most at risk of IP,1 we have often found ourselves unable to internalize these achievements. For example, though those in our social circles congratulate us on our accomplishments, we are often incredulous to their praise. It is important to note that these feelings are not constant, and we fluctuate in and out of them, in keeping with the theory that this construct is dynamic.1 Importantly, these feelings are lowest immediately following the release of examination results, and highest towards the latter one-third of the academic year. We make the suggestion that the inability to internalize achievement is a by-product of the constant stream of high impact examinations not allowing time for true reflection and an appreciation of one’s achievements. The intense nature of a medical school programme cannot be changed however, but we certainly feel that identifying the fluctuating pattern of IP is crucial for providing support to students in a timely manner.

We have also experienced self-perceived fraudulence, where we feel that we are seen as highly knowledgeable individuals, yet do not feel as such. These feelings of inadequacy were only heightened by the COVID-19 pandemic and our isolation from medical school placements. We hypothesize that these feelings arise from a fear of being unable to fulfil our role as medical professionals as well as the role models we see in training. We have felt these feelings ease when given supportive and encouraging feedback from our superiors on placements, in keeping with the positive effects of supportive feedback previously reported.1 In our experience, supportive feedback that normalized a minor lack of knowledge was most effective and took away feelings of inadequacy. Discussing our feelings with peers has also been very valuable, demonstrating and agreeing with the importance of peer-led counselling in breaking down this personality construct.1

Furthermore, we agree that not only does IP hinder academic performance, but it also affects personal relationships. Experiencing bouts of IP has certainly made us feel alienated from our peers who do not share in our experience, and this is at no fault of our peers, but instead demonstrates the clear need for medical schools to promote a greater awareness of this personality construct. Because of our feelings of alienation secondary to IP thought patterns, we invite the authors to consider whether feelings of alienation, lower self-esteem and self-compassion are causative factors for IP, or a product of the construct.

Furthermore, because of the nature of IP, we have felt that we have needed more emotional support from our peers than those who do not experience IP. Relying on peer support from one another, without an appropriate evidence-based support system in place, is not fair on medical students as a whole and does not provide us with optimum support. We also suggest that perhaps the dynamic nature of IP exists because of the fluctuating availability of peer support, and that an organized and consistent support system could instead keep these negative thought patterns in remission

Ultimately, we hope we have demonstrated a clear gap in medical school well-being support exists and should be addressed. Using IP scoring systems such as those demonstrated by Rosenthal et al and incorporating these into a structured and organized support system will encourage good mental health and well-being in the future medical workforce. Discussing IP in the medical literature and hopefully eventually in medical schools too will also help normalize these feelings that are experienced by many, which in itself is a useful mechanism in breaking down this negative personality construct. To this end, we would like to thank the authors for an informative article, and for helping us understand we are not alone in our struggle.