Tailored for Perfection

In the undergraduate English address he delivered during Harvard’s 2020 commencement day ceremonies, Michael Phillips told of the dawning uncertainties he and other classmates felt as they advanced through their years at the College. Although “the more we progressed, the more we pursued,” something had changed. “Our community of collaboration converted to one of crippling comparison … subdued by the darkness of self-doubt.” Impostor syndrome, he said, settled upon him, and “felt like the incessant pain of a paper cut—or worse.” He and his classmates had imagined that during their college years, they would be defined by their “pursuit of passion,” but instead they had become “troubled by the fear of rejection.”

Phillips is far from alone in experiencing such psychological uncertainty, of seeing the joy of attaining goals strangled by the fear and worry of not measuring up, not having the stuff necessary to achieve one’s dreams or succeed within a community of exceptionally capable future leaders.

Impostor syndrome, the phenomenon he references, is thought to affect more than half of all medical students, trainees, and physicians. For many, the associated symptoms of anxiety, emotional exhaustion, and depression can cause them to struggle academically and personally. For some, symptoms can escalate to burnout, suicidal ideation, and even attempts at suicide. And while the syndrome is not considered a mental disorder—it’s not listed in the Diagnostic and Statistical Manual of Mental Disorders—it is of great enough concern to precipitate action by psychiatrists, medical educators, and leading physicians at HMS and elsewhere, all seeking to develop programs and change institutional cultures to alleviate its harms.

Roots of doubt

The term impostor syndrome was introduced in 1978 by clinical psychologists Pauline Rose Clance and Suzanne Imes in a paper in Psychotherapy: Theory, Research and Practice. The work described “feelings of intellectual phoniness” that were prevalent among the select sample of high-achieving women who participated in their study. Despite the outstanding academic achievements of the women, the two researchers wrote, they “persist in believing that they are really not bright and have fooled anyone who thinks otherwise.”

Since Clance and Imes’s early work, researchers have found a notable, at times significant, prevalence of the syndrome in both women and men and across cultures and ethnic groups. A literature review published in Medical Education in Review earlier this year looked at eighteen papers that assessed impostor syndrome in medical students, trainees, or attending physicians throughout the world. The studies reported rates of impostor syndrome between 22 and 60 percent within the specific groups measured.

Among the papers reviewed were two that measured the prevalence of the syndrome in groups of U.S. medical students. One study reported 30 percent of the students had clinically significant impostor syndrome, with perfectionism and the syndrome strongly associated with an increased risk for distress, while another study reported that nearly 40 percent of its participants showed symptoms of impostor syndrome, including feelings of emotional exhaustion and depersonalization. Similarly, two studies of medical students in Pakistan indicated prevalence levels of the syndrome that approached 55 and 48 percent within the respective cohorts. A study involving medical students in Nigeria found nearly 23 percent had clinically significant indications of the syndrome coupled with low self-esteem.

Inside and out

The self-doubts associated with impostor syndrome typically surface during times of transition, when a person’s fears of fresh scrutiny of their knowledge and abilities by a new set of colleagues or classmates arise.

The transition to college, for example, can be difficult.

A 2016 paper in Psychological Medicine found that mental health disorders are common among college students but usually start before they enter college. Unfortunately, these disorders often go untreated and can affect educational and psychosocial functioning in subsequent years.

One of the authors of that paper was Stephanie Pinder-Amaker, an HMS assistant professor of psychology and director of McLean Hospital’s College Mental Health Program. Each year, McLean treats as many as 1,100 students from more than 200 colleges and universities who seek treatment for a broad range of psychiatric illnesses. Much of this influx occurs at the beginning of the academic year, when students confront their new college lives.

The program at McLean takes a multi-faceted approach to addressing conditions such as anxiety, depression, eating disorders, obsessive-compulsive disorder, and substance use disorders, many of which can manifest in individuals with impostor syndrome.

It also takes a holistic approach to college mental health. It works directly with students undergoing treatment and also works with college and university administrators to help them implement systemic changes that support students with mental illnesses. This support can include providing comprehensive counseling services for students and other community members and identifying ways to reshape campus cultures to prevent new problems from developing.

Environmental protection

According to Pinder-Amaker, students point to stress as the number one impediment to campus well-being and academic performance: Feeling like a fraud is a remarkably prevalent stressor.

“If you understand impostor syndrome in the context of the broader range of experiences that can threaten an individual’s sense of belonging or sense of being safe or worthwhile or worthy, there’s a different level of appreciation that leads us to a different set of strategies,” she says.

Since these experiences don’t occur in a vacuum, Pinder-Amaker says that addressing impostor syndrome on campus requires taking a broad view of the ecosystem.

“It’s not enough to inoculate individual students by teaching them coping skills and strategies,” she says. “We want to do more than make it possible for students to merely cope. We want to create conditions in which they can excel and thrive.”

According to Pinder-Amaker, it’s important to develop counseling systems and to implement specific interventions that can address impostor syndrome. These might be something as simple as telling students that the feelings they are experiencing have a name, that they are extremely common, and that their professors and mentors likely have felt, or still sometimes feel, the same way.

Giving it a name, demystifying it, talking about it, and providing research about the prevalence of the impostor phenomenon can be a great help, she says. So can collecting and revisiting positive feedback to ward off feelings of being an impostor.

Equally important is identifying and addressing deeper issues, such as the subtle but significant harms caused by implicit bias, stereotype threat, and microaggressions. These social and cultural factors have been shown to heighten stress and lead to great harm to an individual’s overall health. Such harm also impedes academic performance and thus feeds the loop of questioning self-worth.

Safe space

For students, trainees and faculty, their time at HMS can be filled with circumstances that challenge their feelings of self-worth, especially when confronted with the considerable accomplishments of peers.

Although the School’s students cite their classmates as one of the best aspects of being at HMS, they also report that they often feel that their being admitted to the School must have been a mistake, says Edward Hundert, MD ’84, HMS dean for medical education.

Sometimes, he notes, this kind of self-questioning can be a powerful motivator.

“Education arises from some ingenious balance of challenge and support,” says Hundert.

“Part of the challenge that students face is asking themselves if they’re learning enough compared to those around them. You do want people to wonder what they still need to learn, to wonder what others know that they don’t.”

Yet, it’s vital to create an environment where this type of comparison is replaced by collaboration, where students can share their knowledge, their skills, and their feelings of doubt.

“We’re all here to teach each other and learn from each other,” Hundert says. “It can be especially powerful when a student asks an instructor a question and the instructor says, ‘I don’t know, but let’s work together to find the answer.’ ”

Hundert says the myth of “effortless perfection” is a helpful concept for understanding—and disarming—the potential harmful effects of impostor syndrome.

“It’s not enough to inoculate individual students by teaching them coping skills and strategies. We want to do more than make it possible for students to merely cope. We want to create conditions in which they can excel and thrive.”

The term effortless perfection arose from a 2003 study by a committee of the Women’s Initiative at Duke University, which scanned the social, academic, and cultural environment of women on its campus. Many students described feeling compelled not just to excel in every aspect of their lives but to do so in a way that made it all look easy.

Hundert likens this to a duck swimming in a swift current. On the water’s surface, the duck sits serenely, seemingly floating without effort, while below it is paddling furiously.

That underwater frenzy is what’s going on emotionally for many students when they are faced with the culture of medical school. According to Hundert, the lecture style once common in medical schools helped magnify those feelings.

“Each faculty member would come in and ‘trippingly on the tongue,’ as Shakespeare wrote, give all this incredible detail about a specific biochemical pathway or whatever the subject of the lecture happened to be,” says Hundert.

It seemed so natural, he says, “it was as if you could have tapped them on the shoulder as they were walking down the street on any given day and they would have been able to give you all of that detail without even pausing to think about it.”

The net impression over the course of a school year was that all professors had an astonishing command of the entire breadth and depth of medical knowledge, and somehow each student had to know it all, too. But, Hundert adds, this is far from the truth. Those teachers often prepared hard the night before their lectures so they could make it look effortless.

The new case-based collaborative learning curriculum was designed to create a space of “psychological safety” where students and faculty alike are encouraged to ask questions, show doubt, and admit that they don’t know everything.

The goal, Hundert says, is to help students become the kind of doctors who are always asking how much more they can learn, especially with new knowledge being uncovered at an ever-accerating rate. Toward this end, he says, medical education should not be about the transmission of knowledge but about the transformation of the learner; not the number of facts at a student’s instant command but about how well they can “navigate through information” and continually learn. Helping students overcome their feelings of being the wrong person in the wrong place and exploding the myth of effortless perfection can open a pathway for physicians to continue growing and learning throughout their careers.

All together

As the School revises and updates its education model to build more collaborative lifelong learning, HMS leaders and faculty say it is also important to work on strengthening the School’s mental health and wellness programs, examine its broader social environment and that of the profession and of society, and look for opportunities to create a more supportive cultural context for all students and physicians.

HMS Dean for Students Fidencio Saldaña, MD ’01, says that part of this process of program evaluation is recognizing impostor syndrome and directing students to services and techniques they can use to cope with the stress and challenges they face. Like Hundert, Saldaña feels that stress, properly managed, can be a tool for accelerating learning.

“You don’t want to tip over the line to anxiety,” he says. “There’s a sweet spot of activation and peak performance between too little stress and too much.”

The critical thing is to help the student when that stress becomes too much. HMS has developed several wellness initiatives that offer counseling and support services and, for students who need it, can include referrals for cognitive behavioral therapy or involvement in well-being practices such as yoga, sleep management programs, and meditation.

This effort is part of a much bigger project, Saldaña says. “It’s easy to put a program together. It’s harder to change a culture.”

Making the curriculum more collaborative is important, but other elements of the culture might still favor competition or send signals that make individuals feel they don’t belong.

For example, Saldaña says he’s had to rethink what he asks students to share during “break-the-ice” meetings. He used to ask students to share their name, where they’re from, and one fun fact about themselves.

“You could see the wheels turning as they tried to think of the most impressive fun fact about themselves,” he says.

Lately, he’s instead been asking students to share a favorite childhood memory or share something that brings them joy, which seems to establish a more collaborative spirit in groups.

“Once a student is part of this family, it’s really important to us that we empower them to reach their potential and their own definition of success.”

In that same spirit of building self-worth while easing the tensions inherent within this group of high performers, during the students’ orientation to the School, Saldaña likes to tell them that they don’t have to live up to someone else’s image of success—they define what success means to them.

“We want the students to be able to perform to their full potential, and the impostor syndrome is one thing that may get in the way,” Saldaña says. “As leaders, we have a responsibility to change the culture to make sure that each student can perform to their potential.”

If HMS students are like most medical students, or like most successful people in any field, from time to time they will likely feel that they are not worthy of the success they’ve achieved or are not ready for the challenges that lie ahead.
But Saldaña reassures them that, should they need it, help is at hand.

“Once a student is part of this family, it’s really important to us that we empower them to reach their potential and their own definition of success,” Saldaña says.

Jake Miller is a science writer in the HMS Office of Communications and External Relations.

Images: Traci Daberko (top); John Soares (Pinder-Amaker and Hundert)