The Impostors (essay)

Balaji Varatharaju entered medical school at Adelaide University as a model student, known for his generosity and altruism. He studied, he volunteered at the Red Cross, and helped in aged care, despite suffering from depression and back pain. He wanted to help the most disadvantaged people of Australia, and he took up as an intern in Alice Springs Hospital in 2009.

Quite soon his colleagues noticed his severe lack of clinical knowledge, and his ineptitude in basic tasks like IV cannulation. After he had spent ten months treating hundreds of patients, these concerns were finally raised with the Medical Board, who discovered that he had been expelled from Adelaide University for forging a lecturer’s signature. His certificates were also fakes. He was arrested and charged with forgery, criminal deception, and aggravated assault. He pleaded guilty and received 14 months in gaol.¹

The Medical Board of Australia now routinely cross-checks all qualifications with their issuing institutions, as a matter of course.

Balaji is just one fraud among many. At one end of the spectrum are trained professionals who step beyond their scope of practice or make falsely optimistic claims; at the other end are career fraudsters who skip from one high-profile job to another. These cases are interesting to read about, but they also cast an oblique light upon a fear that quietly nags at many of us in the health professions: that we too might be fakes, pretenders, impostors.

The impostor syndrome was first described by Clance and Imes, of Georgia State University, in 1978.² It is characterised by an inability to internalise success, and the tendency to attribute success to external causes such as luck, error, or knowing the right people. This leads to an inner sense of fraudulence, sometimes called impostorism.

Though not a recognised psychiatric diagnosis, the impostor syndrome is much talked-about in the press. If you read the news or follow the journals, you will have seen headlines about this modern epidemic of self-doubt. You can listen to podcasts about it,³ watch Michelle Obama talk about it on YouTube,⁴ and do the online quiz to find out how badly you suffer from it yourself.⁵ The impostor syndrome is said to be at almost epidemic levels in our society.⁶

Is this true? Probably. The syndrome is estimated to affect 30% to 60% of medical students, residents, and physicians, with a particular prevalence amongst women and people of colour.⁷ It is strongly linked with emotional exhaustion, work-family conflict, job dissatisfaction, poorer organisational citizenship, and the twin curses of burnout & depression.⁸

But what can we do about it? To this author’s knowledge, there are no published studies that assess any intervention’s efficacy in reducing impostorism. Instead you might ask a colleague, and they might say that you should work harder, so you won’t have time for such futile fretting. Or you might ask a large group of people who rate highly on clinical scales of impostorism, so they can tell you what works for them. The strategies these people have described in the literature are quite reasonable: education and self-improvement, external validation of successes, creating supportive work cultures that don’t punish errors, sharing experiences of living with the syndrome, positive mentorship, and setting clear expectations within professional roles.^9,10

All this sounds like excellent advice. However, one question lingers: If we are looking for strategies to reduce impostorism, should we really be asking the people who suffer from it the most? Aren’t they, almost by definition, the very people who are using the wrong strategies? When managing my social anxiety, should I ask a patient in the mental health clinic what strategies they have been using, so I can do the same?

Instead, I would like to propose a different way of looking at the problem. It starts with a question: What if we really are fake?

We are trained since childhood to respect rules we don’t necessarily believe in. To say ‘please’ and ‘thank you’. Not to take what isn’t ours. Not to speak ill of others, even when they aren’t around. Society puts a high price on politeness, which is simply a set of practiced behaviours that we agree are important and good. Politeness is a performance that files away the rough edges of our authentic personalities. Even the word ‘personality’, something supposedly innate to each of us, actually comes from the Latin persona, referring to the role an actor plays on the stage; more literally, it refers to a mask. Our personality is the mask we wear in polite company.

In a way, this relates to Freud’s structural model of the mind, which still still looms large in how we think and talk about our internal conflicts, despite being ill-favoured by modern psychological science. Of relevance to the impostor syndrome is the Super-ego: the internalised aspects of our society, the sense of right and wrong we have been taught, the rules laid down by our parents and by unspoken customs. It is something that is nurtured and developed over many years, and if it fails to develop fully then we are left stunted and psychopathic for the remainder of our lives. This part of ourselves, which we usually think of as being the best, most admirable, most noble aspect of our humanity, is the part that is imprinted upon us by others, thus being explicitly inauthentic to our underlying self. And this is the part where we are meant to incorporate and embody all the virtues of a good doctor.

Similarly, in our work we will present ourselves under the cover of a persona that has been cultivated over time. It comes from our education, both formal and informal. In lectures we learn codes of ethics and methods of resolving moral dilemmas. In the wards and clinics we find role models and gauge the prevailing standards of our time and place. We gain a sense of what role we ought to be playing, and mostly we try to inhabit the role. This is why actors can perform so well as doctors on TV: because we all have a feeling for what a good (or bad) doctor is like. Whether on a stage or at the bedside, a kind of performance is taking place.

Ellen Aronofsky Cole is an American poet and actor, who has written about the experience of being a pretend patient in medical school simulations:¹¹

‘Of course, some students resist the whole idea of role playing. I like to remind them that as doctors, they, too, are playing a role. The doctor must appear professional, competent, and empathetic, even if the patient is difficult, argumentative, noncompliant, or physically repulsive. Physicians who've just argued with their spouse, stubbed their toe, or crashed their car still owe it to their patients to provide the needed attention and care.’

When I first read this, I was taken aback by having my fakeness acknowledged so bluntly. I was taken back to my first year of medical school, when I first sat down with an actor in a room with a one-way mirror, to learn how to interview a patient. As a student I was scared and didn’t know what to say, but I pretended. Now I am a registrar who usually knows what to say, but I am still scared, and still pretending. Every day I pretend, and as I do, I get better at pretending. I watch my seniors, my juniors, my fellow trainees, and I take the elements of them that I admire. I try out a phrase, an emotional manoeuvre, a new way of explaining something, and I watch how my patient reacts. If my tactic works, I incorporate it into my ever-changing ‘doctor’ persona.

This is where Balaji and all the other impostors shed light on us: we all are pretenders. We act out the role society gives us. We might think our noble motives are what separates us from the impostors, but perhaps not. The commentary made by Justice Jenny Blokland on Balaji’s case was revealing: she said that he was ‘motivated in his fraudulent activity to help people in the community rather than hurt anyone’. Balaji was doing what he could to overcome the barriers that kept him from helping the sick people in an underserved part of the country. It is unfortunate that the main barrier was a lack of qualifications and skill. Unlike Balaji, I have the qualifications. I am not always so sure about the skill, but each day I just do the same thing he did. I pretend.

References
1 - Statham L. Fake Doctor Jailed for 14 Months [Internet]. Sydney NSW: Sydney Morning Herald; 2010 [updated 2021 Jun 16; cited 2021 Apr 17]. Available from: https://www.smh.com.au/national/fake-doctor-jailed-for-14-months-20100616-yfxa.html
2 - Clance PR, Imes SA. The imposter phenomenon in high achieving women: Dynamics and therapeutic intervention. Psychotherapy: Theory, Research & Practice. 1978; 15(3), 241–247.
3 - NPR. Impostor Syndrome: How to Overcome Feeling Like A Fraud: Life Kit: NPR [Internet]. Washington DC: NPR; 2021 [updated 2021 Feb 01, cited 2021 Apr 17]. Available from: https://www.npr.org/transcripts/959656202
4 - The Star. Michelle Obama explains impostor syndrome – YouTube [Internet]. Sun Bruno CA: Youtube; 2019 [updated 2019 Dec 13, cited 2021 Apr 17]. Available from: https://www.youtube.com/watch?v=dumm_XfHkmY
5 - Means N. Clance Impostor Phenomenon Score [Internet]. Austin TX: NICHOL.AS; 2014 [cited 2021 May 17]. Available from: http://impostortest.nickol.as/
6 - Martin C. Why impostor syndrome has become epidemic [Internet]. Sydney NSW: The Australian Financial Review; 2020 [updated 2020 Feb 11, cited 2021 May 17]. Available from: https://www.afr.com/work-and-careers/workplace/why-imposter-syndrome-has-become-epidemic-20200205-p53xxp
7 - Bravata D, Watts S, Keefer A, Madhusudhan D, Taylor K, Clark D, et al. Prevalence, Predictors, and Treatment of Impostor Syndrome: a Systematic Review. J Gen Intern Med. 2020 Apr; 35(4):1252–75.
8 - Gottlieb M, Chung A, Battaglioli N, Sebok-Syer S, Kalantari A. Impostor syndrome among physicians and physicians in training: A scoping review. Med Educ. 2020 Feb; 54(2):116–124.
9 - Ibid.
10 - Barr-Walker J, Werner DA, Kellermeyer L, Bass MB. Coping with Impostor Feelings: Evidence Based Recommendations from a Mixed Methods Study. Evidence Based Library and Information Practice. 2020 Jun; 15(2), 24–41.
11 - Cole EA. My Life as a (Fake) Patient. N Engl J Med. 2015 Dec; 373:2302-2303.