Hello, and thank you for joining me today on this virtual DO Day. My name is Cassandra Holup, and I am excited to share with you all about a phenomenon called imposter syndrome. This syndrome is far more common than you may know, especially in the healthcare field. This is a topic that is very important to me, as I am a huge advocate for physician, resident, and student wellness. Without further ado, let's get started. First off, I have no relevant financial disclosures. I do want to point out that the viewpoints and opinions in this presentation are solely mine and do not necessarily represent the views of SOMA or the AOA. So we're going to be asking a lot of why today. I decided on this overarching theme because my first realization that I had imposter syndrome came when I was repeatedly asking myself, why me? I was honored with certain experiences and kept thinking, why? Amidst thinking, why am I qualified to be here giving my opinion, I would be filled with doubt and feel like I did not belong. So we're going to start with that very question, why me, to dive into the definition of imposter syndrome. We will then dive into why we should care about imposter syndrome as healthcare professionals and why this topic is so relevant for DO Day and advocacy. And finally, we will finish off with ways that we can start to address imposter syndrome on a personal level, as well as an institutional level. So a little bit about me. I am a fourth year medical student at the Lake Erie College of Osteopathic Medicine in Erie. I am originally from Chagrin Falls, Ohio, which is about 35 minutes outside of Cleveland. I've applied for this year's match in internal medicine with the hopes of pursuing a fellowship in pulmonology critical care down the line. I'm a proud dog mama to a spoiled rescue mutt named Tilly, who I take for walks daily for my own mental health. Some of my hobbies include working out at a CrossFit gym, hiking, cooking, planting indoor plants and gardening, running, crafting, and traveling. These pictures at the bottom show some of the most important things in my life. One thing that I didn't mention on my last slide is that I am the president of the National Osteopathic Student Medical Association, or SOMA. Throughout the year, I have had many times where I think, why was I elected to run this role? And surely those that chose me must have been fooled. I can't be qualified to lead an organization of 15,000 people. With my role as president, as you may have guessed, I've been tasked with many responsibilities. I've been asked to be a part of several committees, task forces, and join meetings. And I'm the only student in these meetings, leading me to have thoughts like, why am I the only student in this meeting with all physicians? Why did I get this invite when there are far more qualified people to be in this position? Why am I special? I was first introduced to imposter syndrome during a mission trip in Peru in college. I struggled a lot with the subject, not because I didn't understand it, but because I was refusing to accept that I could not find my identity and my faith. I felt like I was not living up to what everybody had expected of me. I wrestled with this feeling a lot during that trip. And as I returned back to a leadership role in my campus ministry group, I eventually overcame this incidence of imposter syndrome. However, the incidence of imposter syndrome that found me during medical school and during my current leadership role has been much harder to deal with. So why am I qualified to be giving this presentation? Because I attempted to combat imposter syndrome on a weekly, if not daily basis. And I felt that I needed to get better strategies to overcome these feelings of inadequacy. While learning more about the topic, I found just how relevant to other medical students, as well as physicians, this issue is, and wanted to open up the conversation about imposter syndrome. And now it's time to do just that. Starting by learning the description of imposter syndrome. I want to start off this section with a series of thoughts to fire up those neurons. Keep in the back of your mind if you've ever thought any of these things. If I were truly intelligent, competent, or qualified, I would know every symptom of every disease. If I were truly intelligent, competent, or qualified, I would get the diagnosis correct the first time, every time. If I were truly intelligent, competent, or qualified, I would excel at every procedure I do. If I were truly intelligent, competent, or qualified, I would always feel confident when speaking to patients. If I were truly intelligent, competent, or qualified, I would never make a mistake. If I were truly intelligent, competent, or qualified, I would never need help. If you've ever felt any of these things before, luckily you're in great company. Some studies have found that up to 60% of physicians experience imposter syndrome, but more on that later. So let's get into the definition of imposter syndrome. While there isn't an official diagnosis or widely accepted medical definition of imposter syndrome, there are many agreed upon features. Dr. Suzanne Imes and Pauline Rose-Klantz first identified imposter syndrome in 1978 while feeling inadequate in their university positions. They noticed that some of their students had also felt this way. They coined imposter syndrome as self-doubt of intellect, skills, or accomplishments most commonly seen in high-achieving individuals. People in this position see themselves as fraudulent and fear that other people will discover their incapability. They have a hard time seeing that the results they achieve are a direct representation of their actions and hard work. I hope you are reading this and thinking, huh, high-achieving individuals? That sure sounds like people in the medical field. If this is what you're thinking, you're absolutely correct. Imposter syndrome is disproportionately prevalent in academics and in the healthcare field. But again, more on this later. In addition to help coining the definition of imposter syndrome, Dr. Klantz developed the Klantz Imposter Phenomenon Scale, which can identify someone as experiencing imposter syndrome and to what extent they're suffering from imposter syndrome. The test is composed of 20 questions scaled from 1 to 5, with 1 being not at all true to 5 being very true. A score of 40 or less or a 2 or less on each question indicates a low suspicion of imposter syndrome with few imposter characteristics. A score between 41 to 60 indicates moderate imposter syndrome characteristics, a score between 61 to 80 indicates frequent imposter syndrome characteristics, and a score higher than 80 indicates intense and severe imposter syndrome experiences. The higher the score, the more impact that imposter syndrome has on a person's life. I'm not going to read all of these questions to you, as you can find the whole test on paulineroseklantz.com, but I again want to highlight some characteristics that might hold especially true in physicians. I have often succeeded on a test or task even though I was afraid that I would not do well. When people praise me for something that I've accomplished, I'm afraid I won't be able to live up to their expectations of me in the future. I sometimes think I obtained my present position or gained my present success because I happened to be in the right place at the right time or because I knew the right people. It's hard for me to accept compliments or praise about my intelligence or accomplishments. I often compare my ability to those around me and think that they may be more intelligent than I am. So now that we've seen that this most commonly can affect physicians at some point in their career, let's take a look at a few tangible examples of imposter syndrome. If you've ever seen The Big Bang Theory, there's a perfect example in season 12, episode 18. If you haven't seen the full series, close your ears or skip ahead because this may contain some spoilers. The background is that Sheldon and Amy are in the running for a Nobel Prize for their work on super asymmetry theory, but there are two other scientists also in the running. These other scientists performed an experiment that proved a theory of Sheldon and Amy's paper. However, this experiment was actually a mistake and these other scientists are trying to reap the credit from all of Sheldon and Amy's hard work. Let's take a look. Good answer. Hey, if we haven't said it before, we just want to say thank you. Yeah, we couldn't have proven super asymmetry without you. Wait, wait, wait. You all heard them say it. We didn't do anything. Sheldon, shut up. Yeah, well, that's rude. No, shut up. Oh, the code word. Thank you. It's strange. A few months ago, nobody paid any attention to us and now all of a sudden we're getting all of these accolades. Yeah. Have any of you ever felt like maybe you didn't deserve it? Leonard, there's something I need to say. Shut up. I'm sorry. Okay? It's crazy. We conclusively proved super asymmetry and yet somehow we still feel like imposters. There should be a term for that. Oh, for crying out loud, there is a term for that. It's called imposter syndrome and you don't have it because you can't have it if you are imposters and you are. We're the ones who discovered super asymmetry. So if anyone's gonna feel like they have imposter syndrome, it's us because we're not imposters. They are! You're imposters and you're frauds! Is that what I would have sounded like? Yeah. Yikes. While Amy points out that these scientists do not have imposter syndrome since they truly are just trying to steal credit for somebody else's work, this does demonstrate some key aspects of the loose definition of imposter syndrome. High achieving individuals believing that their success is fraudulent and not as a result of their work. Let me give you a more tangible example. A fourth year medical student provides care to a patient in a busy ICU on an elective rotation. Since this is the only patient they are caring for, they have extra time to spend with the patient and their family. After taking the time to inform the family about the patient's condition, and the triggers for torsades, the elderly wife of the patient tells the medical student, as soon as you start your residency, I will be leaving my current physician to follow with you. After hearing this comment, the student's first thought should have been, I am going to be a capable physician who will take care of patients well, and this is a flattering compliment. Instead, the student's first thought was, why would this patient who has a relationship with a provider leave that provider and follow with me? I'm not qualified for this, and I'm sure that I'm not as good as any other number of providers for this patient. While this student is not yet licensed to take care of patients, they will be within the next year as a resident. Their training, compassion, and empathy for patients that they have developed during medical school does qualify them as a suitable option for this patient and their family, and the student should have been able to see this. However, their imposter syndrome creeped in and cast a doubt. One last example that might be applicable for some of you watching. A physician who has been practicing medicine for over 10 years has a difficult patient come into their office. A middle-aged man with poorly controlled diabetes had developed unexpected complications. The physician had followed the correct protocols, consulted with a specialist, and adjusted his treatment accordingly. Still, the physician couldn't shake the feeling that they had missed something, that a more competent physician that a more competent doctor would have caught it earlier. The physician ran the case by an endocrinologist friend of theirs who concurred with the management of the patient. Our original physician should have felt relief that they did the most that they could for this patient, but instead of relief, they felt unease. The physician thinks to themselves, no one sees the self-doubt. No one knows how close I feel to making a mistake. If I was just a little better, maybe I wouldn't have missed something. These feelings of self-doubt, uneasiness, and inadequacy are the backbone of imposter syndrome as a condition. While Amy, the neurobiologist, might have a good handle on imposter syndrome, I was still unsure of all of the criteria for the condition until I looked more into it. I learned that in addition to a broad definition of imposter syndrome, Dr. Clance identified six criteria of imposter syndrome that may be present in people with imposter syndrome. These also feed into one another and create kind of a cyclical pattern of imposter syndrome. If you're like me, you haven't heard of half of these terms, but as I read them, you might recognize the feelings of them. So we're gonna go through them one by one. The first identification of imposter syndrome was called the imposter cycle. The imposter cycle is when someone with imposter syndrome either over-prepares or procrastinates when they are faced with a task and expected to succeed. Upon completion of a task, there's a brief sense of success or triumph in each scenario. Despite this sense of accomplishment, there is failure to internalize this sense of success. I'm not sure that I even have to go into examples of both of these response mechanisms, but for completeness sake, I will. Over-preparation is when someone feels like they have to work harder than others to achieve the same goal. This could mean spending eight hours a day after eight hours of lecture, studying for an upcoming exam, reviewing patient charts for hours after your shift is over to make sure nothing was missed during the day, or even taking weeks to complete a DO day presentation that probably could have been done in days if you didn't spend countless hours reviewing the slides and making sure every comma was in the correct place. Over-preparation in itself can lead to the feelings of being an imposter. Since the individual feels like they have to work harder than their other colleagues to achieve the same goal, so they must be an imposter. On the other hand of the spectrum, the imposter cycle describes procrastination as a characteristic of imposter syndrome. Since I am sure that no one knows what procrastination is, I'll tell you. Procrastination is preparing something last minute because it was put off until the deadline. People with imposter syndrome do this because they feel they cannot achieve what is expected of them. So they struggle with even getting started. This leads to those with imposter syndrome experiencing a spectrum of fear, anxiety, and fraudulence, leading to the next task effectively repeating this cycle. Next, let's talk about perfectionism. Perfectionism can be described in many ways, but ultimately it is the need to be the best and achieving success without flaws. Perfectionism has been measured on a multidimensional perfectionism scale created by Hewitt and Flett. This scale measures three dimensions of perfectionism, self-oriented perfectionism, other-oriented perfectionism, and socially prescribed perfectionism. Basically, this is describing that perfectionism can be caused by three factors, setting unrealistic goals for ourselves, setting unrealistic expectations for and criticizing others, and feeling the need to meet expectations set by others in order to gain their approval. Socially prescribed perfectionism most closely resembles a type of imposter syndrome that we're talking about. This characteristic of imposter syndrome brings out hyper-competitive behavior as the imposter has set unattainable standards for themselves. With this characteristic, people will sacrifice their self-interests to make their work perfect and succeed by their own definition. As seen in this image, perfectionism often holds us back. People are less likely to achieve their goals when they are overly critical of themselves and believe that they will not succeed. Next, the superheroism condition in imposter syndrome is an interesting concept where individuals experiencing imposter syndrome feel an overwhelming need to constantly prove their work, much like a superhero always trying to save the day. People struggling with this feature of imposter syndrome are responsible for everything. Just like superheroes carry the weight of the world on their shoulders, people with imposter syndrome often feel that they must save their workplace, save their relationships, or save their projects. Also similar to superheroes, superheroism in imposter syndrome manifests with the refusal to accept help. Many superheroes refuse assistance, believing that they alone must bear the burden. This adds additional workload and can perpetuate the feelings of imposter syndrome if that work doesn't get completed. Auticophobia is also described as the extreme fear of failure, which can be so intense that it prevents individuals from taking risks, trying new things, or even completing simple tasks. Unlike normal nervousness, this fear can be paralyzing and deeply impact one's life. Signs of auticophobia include avoiding challenges for fear of failing, over-preparing to an extensive degree, and experiencing extreme anxiety at the thought of making any mistake. Much like our physician from the earlier example, this fear of failure can be debilitating and prevent someone from ever attempting anything new, or sometimes prevent them from even getting out of bed. This can lead to more self-doubt and more imposter feelings. Next, denial of competence is an overarching theme of imposter syndrome, and it feeds into each one of these other categories fairly well. At its core, the denial of competence phenomenon is the persistent belief that one's achievements are undeserved despite clear evidence of their skill and capability. It's the idea of no matter how much success someone has, they still feel incompetent. Key characteristics of the denial of incompetence include dismissing achievements as luck or external factors, believing that success is due to fooling others rather than actual ability, and feeling unqualified despite expertise or credentials. The denial of competence might be influenced by many factors, comparison to others, early developmental experiences, or societal expectations. Comparing oneself to others and seeing others as more talented can distort self-perception and lead to feeling like an imposter. The denial of competence phenomenon keeps many people trapped in self-doubt and prevents them from embracing their own success. So success should be something to celebrate, not fear, right? Not necessarily in everyone. In the phenomenon of achievement phobia and imposter syndrome, people fear success and feel that achieving success is a burden. Individuals associate achievement with negative consequences, such as higher expectations, increased pressure, and potential backlash from others. It often leads to subconsciously avoiding opportunities that could lead to success. Those with achievement phobia can sometimes avoid promotions, awards, or recognition, self-sabotage their progress due to fear of responsibility, or feel anxious about achieving something meaningful. This fear of success can be just as paralyzing as the fear of failure that we discussed earlier. As you can see on this slide, these characteristics often feed into each other, hence why not only one characteristic defines imposter syndrome, and hence why this is such a chaotic slide. Perfectionism can feed into any one of these characteristics of imposter syndrome, as expectation placed on oneself to be perfect can lead to never getting started for fear of failure or taking way too much time to prepare. I'm not going to belabor the point that all of these work together, but I did want to specifically note perfectionism as tying into each one of these other characteristics, as we as physicians and medical students a lot of the times hold ourselves to an unattainable perfectionism standard. Similar to Dr. Clance's characteristics of imposter syndrome, Dr. Valerie Young, an imposter syndrome researcher, has identified five different types of imposter syndrome. These types all have different priorities and focus areas regarding achievement. So, let's take a look at each of these types of imposters in depth. Have you ever heard, you can do something right 99 times, but that one wrong time is what people remember? Or the much more relatable, you pass an exam, but can't help but focus on all of the questions you got wrong? That is a thought process of the perfectionist imposter with every decision they make. Perfectionists set abnormally high goals that need to be achieved flawlessly. Even if they do succeed in getting tasks done perfectly, perfectionists always feel that they can do better. Rarely do they acknowledge progress or celebrate their achievements. If you're familiar with the Enneagram personality test and you're a number one, these are striking some chords with you. Some key characteristics of the perfectionist imposter include setting excessively high and often unrealistic standards, viewing even minor mistakes as major failures, struggling to delegate tasks due to fear of them getting done incorrectly, and feeling that no achievement is truly ever enough. The perfectionist imposter focuses on how they get something done. Next up, we have the expert imposter. The expert imposter is somebody who believes that they must know everything before they can be considered competent. They feel like a fraud unless they have all the answers, which leads to constant learning, but never feeling qualified enough. This group has a hard time ever believing that they have sufficient information to act successfully as they constantly fear being perceived as inexperienced or unknowledgeable. These individuals are likely to have an abundance of qualifications to support their promotion in a role or involvement in a project, but adopt the belief that they have obtained them through fluke or trickery in the system. The expert does not believe in experiential learning and instead obsesses over acquiring more training. Some may refuse to use their skills until they're qualified enough, where the time to pursue a goal likely will never come as there is a consistent participation in the cycle of needing to know more before feeling ready to overcome a task. The expert imposter might feel like a fraud despite having significant knowledge or expertise, believe that others overestimate their intelligence or skills, have reluctance to speak up due to fear of being exposed, or continuously seek new degrees, certifications, or training to feel incompetent. The expert imposter focuses on how much they know as a matter of success. The soloist imposter believes that success is attained individually and that receiving help does not equate to adequate performance. They often believe that they need to handle things themselves in order to be seen as incompetent or dependent on others. This can stem from a fear that others might judge them or see them as less capable if they ask for help or work collaboratively. Here's how this can often play out. A soloist might take on a project or responsibility alone because they worry that asking for help or working in a team would expose their perceived inadequacies. They fear that relying on others might make them appear weak, unskilled, or incapable. So, they shoulder everything themselves, even if it's too much. Because the soloist feels like they need to handle everything independently, they can take on too much, leading to stress, overwhelm, and burnout. They might be constantly pushing themselves, thinking that if they fail, it will confirm their fear of being an imposter, so they work harder to prove their worth. The soloist may avoid situations where they need to show vulnerability, such as asking for help or admitting when they don't know something. They may seek others for support as a sign of weakness or failure, even though it's a normal and healthy part of working with others. In essence, the soloist is someone who isolates themselves in their work or tasks to avoid feeling like an imposter. Their drive to prove themselves leads them to take on challenges alone, often at the cost of their well-being and authentic connection to others. Bringing back the Big Bang Theory, we can't all be like Sheldon, achieving things effortlessly with maximum efficiency. The natural genius type of imposter have a strong belief that successes should come easily and effortlessly. These people often believe that if they truly have talent or intelligence, they should just click without struggle or hard work. When they encounter difficulties or setbacks, they feel like they have failed, which triggers the feelings of being an imposter, like they don't truly belong or aren't as competent as others think. Here's how the natural genius typically manifests. Natural geniuses believe that if they're truly skilled or talented, successes should come without much effort. They might look back at their past achievements and assume that if something takes too much effort, it means that they're not really good at it. When faced with challenges or failure, natural geniuses might feel like they're failing at something that they should be naturally good at. They might have a sense of shame or embarrassment about needing to put in extra effort to succeed. This can lead to feelings of inadequacy or fraudulence as they worry that others will realize they're not as naturally talented as they seem. They expect to do things perfectly the first time and anything less than that feels like a failure. If they do something and don't get it right immediately, they might feel that they aren't natural geniuses after all, reinforcing their imposter feelings. One of the larger issues with this type of imposter is that they often get frustrated with the learning process. Natural geniuses often struggle with the idea of learning over time. Since they feel like they should have instant mastery, they become frustrated if they don't pick things up quickly. This frustration can make them feel like they're not as talented as others think. The natural genius imposter focuses on how fast can I do it to define success. Lastly, we need to talk about the superhuman imposter. This imposter is one who over excels in work and in every other aspect in their life because they're in constant search of external validation from others to feel worthy. Their success is measured by how much they do and how many roles they can manage. This type of imposter gauges their worth and their identity as an employee, a physician, a friend, a child, a parent, leader of this committee, member of that work group, president of this society, etc. Superhumans tend to push themselves beyond their limits due to the expectations that they place on themselves. They take on multiple tasks, projects, and responsibilities because they feel like they can handle it all and that they must handle it all. The fear of being seen as an imposter often leads to them avoiding delegating tasks, which can result in burnout. They may push through exhaustion to keep up the appearance of being superhuman. They might overcommit to tasks or responsibilities in order to show others that they are capable and deserving. They often fear being seen as lazy, unproductive, or not up to the standards that they've set for themselves. Since superhuman imposters feel the need to always be performing at their best, they often have difficulty taking breaks or relaxing. They might feel guilty if they aren't constantly being productive or studying, as it seems like they're failing at maintaining their superhuman status. Taking time off feels like they're letting their guard down in the fear of being exposed as an imposter lingers. I want to pause here for a second to let all of this sink in. I would be willing to bet that this imposter syndrome does not does apply to most of those with leadership roles in the healthcare field. I know very few, if any, leaders that I have met that only hold one leadership role. While I wish that I was blameless and could not resonate with this type of imposter, I fear that anyone who knows me that could be watching this would call me out on my lie. In reality, reading about this specific type of imposter was, in a way, like I was reading an autobiography. While I hope this is not the case for you, I have a feeling that that is, in fact, the case for many involved in leadership roles. So, we've taken all this time to spend on talking about what imposter syndrome is, the different types of imposters, and the imposter syndrome cycle. Now, instead of asking the question, why me? I want to turn our focus to, why care, and discuss the relevance and importance of recognizing imposter syndrome. A study published in the International Journal of Medical Education in 2020 showed that medical students experience similar rates of perfectionism compared to other student groups, but medical students do experience more imposter syndrome compared to other students. Another study found that up to 80% of medical students experience imposter syndrome, with nearly all students facing imposter characteristics at some point. This issue should be concerning for our educators and concerning for those of us who are The feelings of imposter syndrome progress throughout the first year of medical school, likely due to increased comparison between peers, increased isolation as topics get more difficult, and decreased confidence. Another study showed that imposter syndrome was associated with a higher rate of burnout Burnout has become such a buzzword lately, as we have realized that our current health care situation is not always conducive to a long, fulfilling career, and we see that rates of fatigued physicians have increased. I'm not turning this into a burnout lecture halfway through, but in order to understand the consequences of imposter syndrome, we have to look at the statistics. Specifically, students with imposter syndrome show a higher rate of burnout than Students with imposter syndrome showed significant associations with exhaustion, cynicism, emotional exhaustion, and depersonalization. These feelings can lead to decreased academic performance, a lack of self-confidence, and even mental health issues like anxiety and depression. Many students begin to question their ability to succeed in medicine, and it can become a cycle. The more stressed you are, the more you feel like an imposter, and the more you feel like an imposter, the more stressed out you become. These are the questions that the medical students in the previous study were asked. I want to call your attention specifically to question number seven. I'm willing to bet all of my student debt that every single person watching this at one point in their career would have answered yes to this. While one question alone does not definitively indicate imposter syndrome, I would also venture to say that each of you have felt at least one of these other qualities also. Now, the rationale behind my constant quizzing and giving you questions is not to test you and make sure you're still awake, which I hope you are, but rather to bring light to how common these feelings are and to hopefully encourage people who are having these thoughts that you are not alone. Unfortunately, the relationship between burnout and imposter syndrome seems to be cyclical. When someone starts feeling like an imposter, self-doubt creeps in. This doubt tells them that they are not good enough to succeed or finish what they started. This leads to not having the motivation to finish the task and to procrastination. At this rate, tasks don't get done, and they begin to pile up. As we know, the overwhelming amount of tasks that we have to accomplish is what drives burnout, but it doesn't stop there. When someone is burnt out, they can feel like they failed at their job, role, etc., and thus the cycle begins again. This is a wicked loop that is extremely difficult to break out of. While imposter syndrome is more prevalent among medical students, it's not only medical students in the medical field that experience imposter syndrome. A study done by the Mayo Clinic in 2022 compared the rate of physicians to workers in other fields when it came to feelings of imposter syndrome. The study found that one in four physicians experienced frequent or intense imposter phenomenon experiences. Other studies found this number to be as high as one in two physicians. Several reasons have been postulated to why this is the case. First off, the medical field demands precision, with physicians often facing life or death situations. This high-pressure environment fosters perfectionism in an intense fear of making mistakes, contributing to feelings of inadequacy. Also contributing to the feeling of inadequacy is the fact that physicians are lifelong learners. While this is beneficial for physicians and their patients, encountering new information and technologies can make even seasoned doctors feel like they lack sufficient knowledge, reinforcing imposter sentiments. With all of the new research and technology coming out, there's no possible way for physicians to know everything, and this can lead to feeling like an imposter in our roles. Lastly, I believe that physicians are in a unique position where they have empathy and grace for patients and their colleagues, but not always for themselves. This perfectionist mindset is the perfect setup for imposter syndrome feelings to creep in and cast doubt on our self-worth as providers. These are just some of the effects and feelings of imposter syndrome. There are some heavy words on this slide, and these heavy words show us why it is so important that we recognize and care about this topic, especially since it is so prevalent in our medical students, residents, and physicians. Now that we have explored what imposter syndrome is and why it is important that we care about it, we're going to take a look at why imposter syndrome is relevant on this virtual DO day and in advocacy. As advocates, we might experience imposter syndrome in different ways. You might feel like you're not expert enough in the issue that you're fighting for. Maybe you compare yourself to others in your field, thinking that they're doing it more or doing it better, or perhaps you feel like you're not doing enough no matter how much you've already given to your cause. I remember my first DO day like it was three years ago, almost exactly to the day, sitting at a table with three other medical students and about six osteopathic physicians. I was bright-eyed and ready to change the world on the outside, but on the inside, I was thinking, why am I qualified to be speaking to politicians about these important topics that I feel I know little about? If you have felt like me, the world of political advocacy can be filled with imposter syndrome. While the AOA does a phenomenal job preparing us as advocates, and the selected advocacy topics are pertinent to students and physicians, I couldn't help but feel like I was out of place and that I didn't belong, and that everybody was going to discover that I was an imposter. Unfortunately, imposter syndrome can hold us back in advocacy. It makes us question our worth, our abilities, and ultimately, it can cause us to shrink back from the very work that's so important. We might hold back from speaking up in meetings or hesitate to take leadership roles because we don't feel qualified enough. We might second guess our contributions, thinking that they're not significant, when in fact, they are significant. In a world where advocacy often depends on boldness, persistence, and resilience, imposter syndrome can keep us from stepping into our full power. No matter what type of work we're advocating for, imposter syndrome can creep in and make us feel like we're not doing enough or that we don't belong in the work that we're doing. As physician advocates, we're often standing up for marginalized communities, pushing for social change, and standing up for our patients at the most vulnerable part of their lives. And let's be real, this work is hard. It's emotionally taxing, it's never ending, and it can feel like we're swimming upstream most days, when our resolutions don't get passed, when our congressional meeting gets canceled last minute, or when someone tells us straight to our face that what we are asking for just isn't possible. It's easy for us to doubt ourselves when this work feels overwhelming or when we encounter setbacks. Are you motivated to attend the in-person DOJ yet? I hope so. Now, the last section of this presentation will focus on how to deal with imposter syndrome. Why not start seeking ways to mitigate and combat imposter syndrome? While I wish I could tell you that this is going to be an easy fix, I'm afraid, like every other problem in healthcare, this is going to take time and require large-scale changes on a personal and institutional level. Now, I'm going to let you in on something that probably isn't a secret at this point. Writing this next section exacerbated my imposter syndrome immensely. I thought, I don't even have this figured out in myself. What qualifies me to give you advice on how to deal with imposter syndrome? Now, I'm not proclaiming to be an expert or have this figured out. This section is full of adjustments that I have found worked in myself and some solutions that I found while reading about this topic that might just work if they're implemented vastly and correctly. Now, I've left you in suspense long enough. I am, in fact, very much looking forward to participating in my fourth D.O. Dan Capitol Hill in person in just a few days. Will I still experience imposter syndrome despite this being my fourth time attending? Absolutely. But with some of these tips, I hope that I and you can overcome these imposter feelings. First, we need to acknowledge that these feelings of doubt are normal, but they don't define us. Everyone, even the most seasoned advocates, feels like an imposter at times. Recognize that you are not alone in this. Second, we need to reframe our thoughts. When we catch ourselves thinking, I am not qualified, we need to remind ourselves of the skills, experiences, and passion that we bring to the table. Our lived experience and our dedication to the cause are more than enough. We don't need to be perfect to make a difference. Third, we need to celebrate our small wins. Advocacy is a long road, and sometimes we get so focused on the big picture that we forget to acknowledge the progress that we've made along the way. Every conversation with congressional staff, every acknowledgement signed, every person reached, these are all victories and they all matter. Don't let imposter syndrome steal our recognition. Finally, we need to seek support from others. Advocacy work can feel isolating, especially when we carry the weight of imposter syndrome, but lean on your community, whether it's fellow advocates, mentors, or friends, because they can remind you of your value, your contributions, and the change that you're creating. Now, continuing on how to deal with imposter syndrome, I want to shift the focus from imposter syndrome and advocacy and shift it to our lives as healthcare professionals. So what is something that all imposters have in common? They need constant reassurance that they are important and that their work is valued. I have the absolute privilege of having so many friends who are cheerleaders for me. No matter what the situation is, I know that these people are going to have my back 110% of the time. They also build me up and remind me that I am meant to be at the table, that I am meant to have this voice and to use it. When I ask, why me? My army in the corner shouts back, because you are worthy. When I was on rotations with all allopathic physicians and residents, I began to question why I was in that environment as a DO student. I must add, I was never discriminated against by any of these physicians or residents. The doubt came from myself and from my own feelings of inadequacy. I have gotten enough confidence instilled in me by my good friends at the NBOME as well as the AOA of why it is so important to have osteopathic physicians and students as part of the healthcare team. This past year, I have grown deeper in my osteopathic identity and truly embraced the osteopathic philosophy. Realizing that I am a valued member of the osteopathic family has been a game changer for me as well as my patients. Lastly, I have started striving for excellence rather than perfection. Remember that half marathon picture from my intro slide? It took me two hours and 32 minutes to run that race. Was it perfect? By no means, but was I proud of myself that I got out of bed and completed an excellent goal of mine? Definitely. Being a fourth year, as I said before, I applied to residency in September. My original goal was to get interviews at all of the places that I applied to. Once the invites started coming in, I had to set a more realistic expectation for myself. Did I get a 100% perfect interview rate? No way, but did I interview at excellent hospitals where I would be honored to complete residency? Definitely. Finishing up this year, I wanted to get five research posters and projects done with residents at my rotation site. Come on, a fourth year medical student post-interview season finishing five research activities? I should have seen that that was unrealistic back in December. Did I complete all five projects? No way, but did I complete one excellent project wholeheartedly and build excellent, stronger relationships with my residents with this one project? Definitely. These were all things that I have been doing to try to combat my own imposter syndrome. If those don't work for you, here are some other personal level changes that we can make to combat imposter syndrome. We can change our thinking, attitudes, and actions to combat this phenomenon. As I mentioned before, I've surrounded myself with positive leaders, role models, and friends from many different medical specialties and many different walks of life. Having these people in your corner will remind you of your successes and celebrate them with you. Internally, we can modify our mindset to overcome the feelings of imposter syndrome. Imposter syndrome focuses on successes of performance. By shifting our mindset to be centered more around learning, this enables us to learn, fail, and strengthen our skills. This is applicable in every stage of our medical career from student to resident to physician. Similarly, we can attempt to have a beginner's mindset when taking on new challenges. Often, the feelings of imposter syndrome are triggered when developing a new skill. The inexperience can lead people to believe that they are inadequate, when in reality, they're not providing themselves the grace to learn and develop this skill. Having the mindset to allow for grace and allow for learning allows us to learn openly and creatively when thinking of how to overcome obstacles or complete a task successfully. Next, finding a mentor. Mentors play an integral part of the learning process in all stages of our training. Having someone with a little more experience to bounce ideas off of or even to just get affirmation can be extremely beneficial for confidence and lessen the feelings of imposter syndrome. Intern, you can then be a cheerleader or mentor for someone else. Remind them of their successes and celebrate with them. One of my mentors in college would always tell me, grief shared is half grief and joy shared is double joy. This goes just as well for someone who suffers with imposter syndrome. Bringing up these feelings to someone you trust and sharing these feelings with them will lessen the burden on you and this person will be able to support you. And vice versa, when you share your successes and joy with someone, they're likely to double your joy and cheer you on. In addition to personal level changes, it is our responsibility as physicians or future physicians to try to implement large scale changes to help each other deal with imposter syndrome. First, we have to change the stigma that physicians can never be wrong. Having the type A personality in medical school, we all know too well that there are unrealistic expectations placed on us by our professors, our parents, society, and ourselves. I fully believe that we do not give ourselves the grace in the space to be wrong because our society looks up to us as leaders in our communities and instills that physicians have to be the most educated on every single topic. I warned you, these fixes are not going to be easy. How do we convince all of society that yes, we are experts in our field. Yes, we are the most up-to-date on medical advancements. And yes, we can diagnose and treat their mind, body, and spirit, but at the same time, convince society to allow us to make a mistake and to give us the grace and empathy that we give them as patients. Now, this is not me advocating to commit malpractice and to intentionally do wrong by our patients. However, we need to remember that physicians are still human. Making mistakes is human nature. And as physicians, we need to be allowed that nature. In the wise words of Pam Beasley, pobities nerfect. Looking inwards towards our healthcare culture, we need to stop romanticizing the idea of being busy all of the time. This might be a generational flaw, but I cannot tell you how many conversations I overhear from students. I didn't get any sleep studying for this exam, volunteering at this organization, finishing up this research paper, This is often met with the response, that is so impressive. You'll never guess what I did last night. Usually followed by an equally as long list of tasks accomplished by their colleague so that they can feel equally as successful or important, or in other words, so that they don't feel like an imposter medical student. Comparing busy schedules does not stop after medical school, as I have heard these same conversations at conferences and meetings with physicians as well. We need to start prioritizing the concept of rest in our students. Not only will this combat burnout, but stopping a route of comparison among students is sure to lessen the incidence of imposter syndrome. It should not be a surprise that there is a stigma around mental health and medical education, and that this affects the learning and wellbeing of students. There is discourse on whether or not to disclose the mental health challenges students face, or keep them hidden and try to deal with them internally. This struggle causes further distress in students and can lead to increased feelings of imposter syndrome. I swear this is still not a burnout lecture, but as we learned earlier, imposter syndrome leads to higher rates of burnout, and in turn, burnout leads to more feelings of imposter syndrome. So the treatment should be linked to both. Changing the stigma around medical education would help decrease rates of both imposter syndrome and burnout. It would lead to less feelings of inadequacy in students, and therefore, less rates of giving up on this long-term learning goal. Now, these are big level changes and big changes on a personal level. They will not be achieved overnight, and they will likely take some time to see these large scale changes. But like we tell our patients, any progress toward the end goal is a step in the right direction. Oftentimes, the most difficult part is getting started. I hope this talk today inspires someone to get started with changing their mindset regarding themselves and the profession that we have dedicated our lives to. The last thing I will leave you with is this. Remember, imposter syndrome does not define you. Your passion, your dedication, and your unique voice do define you. So when that voice of doubt creeps in, remind yourself that you belong in the work you're doing. You have the power to make a difference, and the world needs your voice. Keep showing up, keep advocating, and most importantly, keep believing in yourself. I'm incredibly thankful that you were able to join me for such an important topic. I want to open this discussion of imposter syndrome so that we can continue the conversation and to help each other get in a mentally better place. If any of these things stuck with you and you would like to discuss them more in detail, please don't hesitate to reach out to me. I would be honored to serve as someone to talk to or be someone in your corner cheering for you along your journey. These are my references. And again, I want to say thank you, and I look forward to seeing you all at this in-person DO Day in just a few days. Thank you. ♪♪

imposter syndrome

Cassandra Holup

medical students

self-doubt

burnout

Dr. Valerie Young

perfectionism

healthcare community

mentorship