Prevalence and Severity of Imposter Syndrome among Surgical and Medical Residents in Makkah, Saudi Arabia

Introduction:

Imposter syndrome (IS) or impostorism is defined by a persistent feeling of self-doubt and the fear of being exposed as an intellectual phony 1, 2. It is associated with psychological features like perfectionism, neuroticism, and anxiety, and it can contribute to stress, lack of motivation, and an inability to enjoy successes 3, 4. Those with IS are unable to internalize a sense of accomplishment, competence, or skill, despite evidence of ability 5. instead, they tend to contribute success to external factors such as luck and help from others 2. As a result of their fear of failure, persons who suffer IS may be less inclined to apply for promotions, resulting in a lack of diversity in leadership roles such as deans or department chairs in academic medicine 1, 6. In general, people believe they are less intelligent and capable than others think they are 1. Legassie, Zibrowksi, and Goldszmidt found a negative link between feelings of IS and personal achievement scores in a 2008 study 7 . As reported by Schubert & Bowker, IS has significantly negative correlation with self-esteem 8. Clance and Imes were the first to describe it in a group of high-achieving women in 1978 6. Since then, the term IS has been noticed and reported at similar levels for both genders 9. Medical students may find the transition from preclinical to clinical training to be particularly difficult 2. Importantly, IS is widely spread within the medical field (6). It is recognized to have an impact on all levels of medical training, beginning with medical students and extending through transition stages and even into senior faculty 6. The prevalence of IS has been estimated to range from 22% to 60% in several studies involving students, trainees, and practicing physicians from various nations 6. For example, in Saudi Arabia, IS is very common among young adults, approximately 57.8%. Significant impostorism was found in 22% of Nigerian medical students and up to 80% among Harvard medical and dental students 10, 11. Additionally, in trainees with risk factors including low self-esteem, feminine sex, and being in the medical culture the rate of IS is between 33 to 44% 12, 10. As reported in the United States, among medical students, the IS rate for men and women is 23.67% and 49.4%, respectively; among residents, the IS rate was similar to medical students, with 41% in women and 24% in men 10. IS must be recognized, acknowledged, and tackled on both individual as well as universal levels to increase the pipeline of diverse candidates in academic medicine 6.

We carried out this study to determine the prevalence and severity of IS among surgical and medical residents in Makkah, Saudi Arabia.

Methodology:

From December 2020 to July 2021, all 207 medical and surgical residents from Makkah hospitals were invited to complete the cross-sectional questionnaire.

The research protocol was reviewed and approved by the University of Umm Al Qura's Ethics Committee and received ethical approval (HAPO-02-K-012-2022-02-962)

A retrospective cross-sectional survey was conducted by utilizing the Clance Imposter Phenomenon Scale (CIPS). The survey was distributed to Makkah city hospitals residents between December 2020 and July 2021 through social media platforms in an online version due to COVID-19 protocol preventive measures. The inclusion criteria were any medical/surgical residents in Makkah hospitals' residency program. Medical students, interns, and consultants were excluded. The informed consent was gathered from all participants by an online version. Any questioning and querying about the study from respondents were answered by the researchers. The required sample size to achieve the research was estimated by Epi Info™ 7.1.5 (Center for Disease Control and Prevention; Atlanta, Georgia, USA). The Clance Imposter Phenomenon Scale (CIPS) has 20 questions to help individuals determine IS characteristics and their severity. The questions are scored with a five points scale to assess the level of agreement with the statements. In addition to (CIPS), the residents were inquired to complete a short demographic questionnaire.

Data analysis:

Data were extracted, revised, coded, and transferred to statistical software IBM SPSS version 24 (SPSS, Inc. Chicago, IL). All statistical analysis was done using two-tailed tests. A P-value less than 0.05 was statistically significant. Regarding Clance IP Scale for imposter syndrome severity, the overall score was obtained by adding the discrete score for each statement. The overall score ranges from 20-to 100. Respondents with a total score of 40 or less were labeled as having few Imposter characteristics (low IS). Those with a score between 41 and 60 are labeled as having moderate IS experiences. For respondents scored 61 to 80 frequently have Imposter feelings (High IS); and a score higher than 80 means the respondent often has intense IS experiences. Descriptive analysis based on frequency and percent distribution was done for all variables, including the Resident’s personal data, residency type, and year. Also, frequency distribution for all items of Clance IP Scale was tabulated. Crosstabulation was used to assess the distribution of residents’ severity of imposter syndrome by their personal data. Relations were tested using Pearson chi-square test and exact probability test for small frequency distributions. Independent t-test with One Way ANOVA were used to test the difference between residents regarding their total IS score. Results

A total of 207 residents fulfilling the inclusion criteria completed the study questionnaire. 136 (65.7%) residents were females and 144 (69.6%) were single. Regarding residency program, 111 (53.6%) residents were at medical residency program and 96 (46.4%) were at surgical residency program. As for residency level, 116 (56%) residents were at their first residency year (R1), 39 (18.8%) were at 2nd residency year (R2), 30 (14.5%) at R^{3, 12} (5.8%) at R4, and only 10 (4.8%) at R5 (table 1).

Table 2. descriptive of imposter test items among surgical and medical residents in Makkah city hospitals, Saudi Arabia. 92.3% of residents could give the impression of being more competent than they are. 90.3% were often afraid of failing at a new assignment, 89.4% were disappointed and thought they should have accomplished much more, 88.4% of residents succeeded on a test or task despite being afraid and were often worried about not succeeding with a project or an exam.87.4% rarely do a project or task as they would like to do it, tend to avoid evaluations if possible, and dread others evaluating them. An exact 71% sometimes feel or believe that their success in life or career has resulted from some error. The residents' overall scores ranged from 22-87, with a mean score of 60.4 ± 10.3.

Figure 1. severity of imposter syndrome among surgical and medical residents in Makkah city hospitals, Saudi Arabia. A total of 8 (3.9%) residents had low level of imposter characteristics, 95 (45.9%) had moderate level of imposter characteristics, 98 (47.3%) had high characteristics level while 6 (2.9%) had intense imposter feelings.

Table 3. distribution of residents’ severity of imposter syndrome by their personal data. High to intense imposter feelings were detected among 54.4% of female residents compared to 42.3% of males with recorded statistical significance (P=.049). On the other hand, surgical residents, and residents at their first years of residency showed insignificantly higher imposter feelings than others (51%, 61.5% for R2 residents; P> 0.05 for all).

Table 4. distribution of residents’ imposter syndrome score by their personal data. The mean score was significantly higher among female residents (61.8 ± 9.7) than male residents (57.7 ± 11.0); P=.006. All other factors were insignificantly affecting the resident’s imposter syndrome score.

Discussion:

The current study demonstrates that the prevalence of IS among surgical and medical residents is high, (93.2%) of the participants showed moderate to high imposter characteristics similar to other trainees at the same or different stages of training 1, 13, 14. This might result from the nature of the residency period as the responsibility increases as well as the expectations. Females have a significantly higher mean imposter score than males. Similarly, the severity of imposter characteristics was higher in female residents than male residents, which is in line with other studies on students and residents 1, 10, 13, 14.

The current findings are consistent with a study done in Saudi Arabia which showed a high prevalence of IS among female adults and associated with depression and stress 15. In addition, this may be due to the difference in coping mechanisms between males and females, as males avoid situations where they feel vulnerable, and females are more likely to manage IS by competing harder and facing their doubts 16.

On the other hand, Sullivan's study on pharmacy residents disclosed no correlation between gender and displaying IS, which is consistent with studies conducted in the non-medical population 9, 17, 18. These findings should warrant future research projects to study IS in different workplaces as the work culture may explain the gender difference in the severity of IS.

Interestingly, as in Legassie, Bhama, and Oriel's studies, there was no statistically significant difference between residency level and exhibiting impostorism, which is similar to our results 10, 13, 14, 19. Furthermore, in this study there was no statistical difference between medical and surgical residents. Marital status was also not a significant factor to show impostorism. All these are in line with Legassie’s study 14.

Regarding Legassie’s study, the findings warrant the program directors regarding the new residents with IS who may encounter a feeling of self-doubt, burnout, depression, and anxiety which need further studies. The current study doesn't evaluate the association of IS with anxiety, depression, and burnout. IS may affect residents mental health which impacts the patient care quality and outcomes 20. Local mentoring programs should be implanted to identify IS in residents considering trainees' mental health. As shown in Baumann’s study, most residents reported that small IS wellness sessions are practical measures, and they are comfortable recognizing IS among them 7.

Conclusion:

In conclusion, the prevalence of IS is high among medical and surgical residents. Except for gender, there were no factors associated with IS. Preventive measures should be taken to identify and treat IS. Future studies should focus on other subspecialties, different workplaces, cultures and to assess the association between IS and the level of training, specialty, predisposing psychiatric diseases, and long working hours.

Limitations:

The limitations of this study are its retrospective design, questionnaire-based, self-administered, and convenient sampling; results may change with a larger population. Furthermore, the ability to reach residents depended on forwarding the link to them by colleagues and students.

Acknowledgement:

Special thanks to Makkah residents for their participation in the study.

Funding statement:

The authors did not receive any funding.

Data availability:

All data are available within the article.

References:

1. Villwock JA, Sobin LB, Koester LA, Harris TM. Impostor syndrome and burnout among American medical students: a pilot study. Int J Med Educ. 2016;7:364-9.

2. Bravata DM, Watts SA, Keefer AL, Madhusudhan DK, Taylor KT, Clark DM, et al. Prevalence, Predictors, and Treatment of Impostor Syndrome: a Systematic Review. J Gen Intern Med. 2020;35(4):1252-75.

3. Levant B, Villwock JA, Manzardo AM. Impostorism in American medical students during early clinical training: gender differences and intercorrelating factors. Int J Med Educ. 2020;11:90-6.

4. Wang KT, Sheveleva MS, Permyakova TM. Imposter syndrome among Russian students: The link between perfectionism and psychological distress. Personality and Individual Differences. 2019;143:1-6.

5. Bechtoldt MN. Wanted: Self-doubting employees—Managers scoring positively on impostorism favor insecure employees in task delegation. Personality and Individual Differences. 2015;86:482-6.

6. Rivera N, Feldman EA, Augustin DA, Caceres W, Gans HA, Blankenburg R. Do I Belong Here? Confronting Imposter Syndrome at an Individual, Peer, and Institutional Level in Health Professionals. MedEdPORTAL. 2021;17:11166.

7. Baumann N, Faulk C, Vanderlan J, Chen J, Bhayani RK. Small-Group Discussion Sessions on Imposter Syndrome. MedEdPORTAL. 2020;16:11004.

8. Schubert N, Bowker A. Examining the Impostor Phenomenon in Relation to Self-Esteem Level and Self-Esteem Instability. Current Psychology. 2019;38(3):749-55.

9. Alrayyes S, Dar UF, Alrayes M, Alghutayghit A, Alrayyes N. Burnout and imposter syndrome among Saudi young adults. The strings in the puppet show of psychological morbidity. Saudi Med J. 2020;41(2):189-94.

10. Bhama AR, Ritz EM, Anand RJ, Auyang ED, Lipman J, Greenberg JA, et al. Imposter Syndrome in Surgical Trainees: Clance Imposter Phenomenon Scale Assessment in General Surgery Residents. J Am Coll Surg. 2021;233(5):633-8.

11. Holliday AM, Gheihman G, Cooper C, Sullivan A, Ohyama H, Leaf DE, et al. High Prevalence of Imposterism Among Female Harvard Medical and Dental Students. Journal of general internal medicine. 2020;35(8):2499-501.

12. Gottlieb M, Chung A, Battaglioli N, Sebok-Syer SS, Kalantari A. Impostor syndrome among physicians and physicians in training: A scoping review. Medical Education. 2020;54(2):116-24.

13. Oriel K, Plane MB, Mundt M. Family medicine residents and the impostor phenomenon. Fam Med. 2004;36(4):248-52.

14. Legassie J, Zibrowski EM, Goldszmidt MA. Measuring resident well-being: impostorism and burnout syndrome in residency. J Gen Intern Med. 2008;23(7):1090-4.

15. Kumar S, Jagacinski C. Imposters have goals too: The imposter phenomenon and its relationship to achievement goal theory. Personality and Individual Differences. 2006;40:147-57.

16. Sullivan JB, Ryba NL. Prevalence of impostor phenomenon and assessment of well-being in pharmacy residents. Am J Health Syst Pharm. 2020;77(9):690-6.

17. Fried-Buchalter S. Fear of success, fear of failure, and the imposter phenomenon among male and female marketing managers. Sex Roles. 1997;37(11):847-59.

18. September AN, McCarrey M, Baranowsky A, Parent C, Schindler D. The Relation Between Well-Being, Impostor Feelings, and Gender Role Orientation Among Canadian University Students. The Journal of Social Psychology. 2001;141(2):218-32.

19. Leach PK, Nygaard RM, Chipman JG, Brunsvold ME, Marek AP. Impostor Phenomenon and Burnout in General Surgeons and General Surgery Residents. J Surg Educ. 2019;76(1):99-106.

20. Cohen MJ, Kay A, Youakim JM, Balaicuis JM. Identity transformation in medical students. Am J Psychoanal. 2009;69(1):43-52.