As the summer swings past full gear, I begin my final year as a chief resident in otolaryngology. Watching familiar faces fade and be replaced with new, eager trainees filling the ranks of the hospital, I reflect on the message I wish I could have imparted to my younger self almost five years ago as I began my training.
It began on the path leading up to residency, when I eagerly opened the online form that contained feedback about my performance during my subinternship.
“She was very quiet.”
Hidden between superlatives and comments praising my work ethic, the singular comment felt like a death knell in my evaluation in otolaryngology. In a competitive surgical subspecialty, being perceived as “quiet” seemed hardly a compliment. The cognitive dissonance of the shame I felt reviewing that feedback felt at odds with what I had experienced in a clinical setting. Many of the attendings I so admired could be called nothing but quiet—it hardly took away from their brilliance, surgical skills, or patient care. And yet this was the first time I distinctly remember feeling that sinking feeling in my stomach—the fear that I did not belong. The academic advising deans at my medical school must have agreed on the hidden unfavourability of that adjective, as the comment quietly disappeared from my final summative evaluation.
Impostor phenomenon was first described by psychologists Pauline Clance, PhD, ABPP, and Suzanne Imes, PhD, at Georgia State University in 1978 (APA PsycNet. https://doi.org/10.1037/h0086006). In their seminal paper that has now been cited more than 4,400 times, they describe high-achieving women from a sample of undergraduates, medical students, graduate students, and faculty who harbored this feeling of being exposed as a fraud despite their objective academic success. Referred to as impostor phenomenon or impostor syndrome, it has been widely studied across broader groups, including minority groups and physicians across all gender and racial boundaries. Drs. Clance and Imes proposed fundamental childhood family dynamics that primed students for the impostor phenomenon. In academic medicine, I believe that priming continues through explicit and implicit values that are extolled in medical school, residency training, and beyond.
Coming into medical school with a goal of grappling with challenges in healthcare access, I had a vague interest in primary care. After coming face to face with the fulfillment I felt on my surgical rotation, I had finalized my decision late into my third year to apply to otolaryngology. Despite early research experiences in the field, my irrational fears that I wasn’t like my peers who had been planning for their neurosurgery and orthopedic surgery careers since birth roared into focus. In a fascinating study on perception, personality, and identity formation, I was awarded a peer-led “Dark Horse” award, for 0% of my medical school class predicting that I would match into my surgical subspecialty on a pre-match survey of my classmates.
The hidden curriculum of value attribution to personality characteristics starts early in training. As a medical student, a group of residents asked me what it was like working with one of the new fellows who had just started at the beginning of the year.
“Oh, she is really nice!” I responded, having had positive interactions during my one-week rotation.
A collective groan emanated from the mixed gender group. After my initial confusion, I read between the lines—the collective unstated conclusion that being nice and being competent were mutually exclusive qualities. That fellow was a powerhouse who ended up winning fellow-of-the-year at graduation, not only for her incredible surgical skill but also for her dedication to resident teaching.
It brought into clarity something that seemed to be mutually understood—that a “nice and quiet” female surgeon would find it challenging to be immediately respected. As a junior resident within the operating room, I was reminded that I was not aggressive, loud, or confident enough—reinforcing my omnipresent level of impostor syndrome. For years, I walked through residency training wrestling with these feelings, as if I were stranded on a desolate island, staring out into the water while everyone else was sailing by me with ease.
As a resident, when I walk into patient rooms, I have been called a phlebotomist, nurse, nursing aide, janitor, and almost every possible staff position other than a doctor or a surgeon, whether or not I wear a pristine white coat with my name and credentials embroidered on it. When over-educated parents versed in ChatGPT and PubMed papers refused to talk to me in clinic visits, I feared that they saw straight through my fraudulent veneer.
Academic medicine is a ripe breeding ground for impostor syndrome. It has already been instilled in every step of the marathon to arrive at its destination. The feeling that we are behind in the competitive race towards the best medical school or residency program, or fellowship, or attending job, or National Institutes of Health grant, or promotion is a ubiquitous and ever-present feeling.
“I am not doing enough,” is the constant thought that dogs my daily tasks.
Trying to balance clinical work while running on the eternal hamster wheel of research projects I am eternally delinquent with—and trying to retain some semblance of relationships with friends and loved ones—seems an impossible task.
And then there is the sinister underbelly of that thought, the one that lurks on the undersurface waiting for a moment of weakness to rear its head.
The thought that maybe “I am not enough.”
Midway through intern year, as I was struggling with the dynamics of the microscope and maneuvering my short arms to insert an ear tube, one of my female attendings turned around and told me, “You know, there were moments in residency when I wasn’t sure if I could do this.”
Hearing those unprompted words felt like a release of weight. I exhaled a breath I didn’t even realize I was holding. But the admission was the realization that I was not alone. And in my conversation with both female and male residents, quiet and loud attendings, I have discovered that many of these feelings are universal. They simmer under the surface and rear their head during key moments you least want them to arrive. It took me years to realize that my level of confidence stemmed from my internalized self-perception of competence. It was hard to project confidence in something I felt like I didn’t deserve.
The interplay of fundamental bias with impostor syndrome is also one that will never fade. I recently watched a patient question the surgical competency of a nationally renowned expert in her field and request a referral to a male colleague. As infuriating as it was to watch, it oddly brought me peace to understand that some biases would never change, no matter what level of success I achieved in my career. Earlier, when patients refused to be seen by me, I worried that they saw through my insecurities.
Belonging is a term that has diffused through the academic speak of diversity and team building. But the truth is that many of us walk around feeling like we don’t belong in different ways. As we look around the room, and our eyes assess and survey the external markers of those who we feel belong, we are blinded by the veneers of those who may be feeling like outsiders at the same time. We see ourselves alone on the deserted island surrounded by sailboats, when in reality we are all standing on the island together with our backs to each other, individually staring out to sea.
Whether it is our name or gender, ethnicity, or institutional lineage, the faces in the room that we know or do not know, many of us walk into the room and feel like we do not belong in one way or another. There are deliberate changes we could make in our specialty and with one another to improve the sense of belonging. We can celebrate confidence as a virtue as much as we celebrate vulnerability. Through both explicitly stated words and implicitly understood actions, we can help redefine what strength and weakness and success and failure are.
“I’m not doing enough” may be a thought that never quite escapes my head. But regardless, I will always know that I am enough.
Dr. Rahman is a PGY-5 in the department of otolaryngology–head and neck surgery at the Stanford University School of Medicine in Palo Alto, Calif., and a resident member of the ENTtoday editorial board.
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