Assessment of burnout and impostor phenomenon in international medical students

Introduction. Impostor syndrome among medical students

The concept of impostor syndrome distorts our perceptions of our skills, performance, and self-worth. It manifests our insecurities and anxieties, such as failing, being judged, and not being good enough. Behavioral changes in students and health professionals can be attributed to the impostor phenomenon, although further research on these characteristics in these populations is needed⁽¹⁾. The impostor phenomenon is frequently seen among students starting university, especially in highly competitive and intense fields that require intensive study, like medicine^(2,3).

Admission to and the context of medical schools are extremely competitive and intense, laden with unspoken performance expectations which can become detrimental to well-being and training in the absence of sufficient institutional support⁽⁴⁾. The steady accumulation of experience is a genuine indicator of a skilled physician. Lifelong learning and skill development are sometimes overshadowed by impostor syndrome. Teachers anticipate that students’ performance anxieties will go away with time, but studies reveal that self-doubt impacts physicians at all stages of their careers. Confidence can be steadily undermined by frequent self-questioning regarding abilities and knowledge⁽⁵⁾. This pattern called the impostor syndrome is associated with high stress levels, psychological discomfort, self-defeating or self-handicapping behaviors, underperformance and, eventually, burnout^(6,7).

Students and physicians with impostor syndrome often struggle to interpret feedback effectively. Unspecific positive feedback feeds into their sense that they are deceiving people, while general negative criticism validates their feelings of being an impostor. Their self-perceived performance and their actual performance may diverge significantly as a result⁽⁸⁾.

Any kind of feedback can be undermined by insecurities, making it more likely to be detrimental or disregarded, depending on the situation. When someone lacks confidence in themselves, hearing negative feedback from others may be extremely upsetting and reinforce feelings of inferiority. Positive criticism is also frequently disregarded by impostors, because they do not believe that they are as skilled as the feedback implies. Although avoiding negative feedback receives a lot of attention, the consequences of ignoring favorable input are rarely considered⁽⁹⁾.

Those who experience impostor syndrome are less likely to speak up or give answers and information, compared with their unaffected colleagues.  This may result in intrinsic disparities in learning style and the requirement to adjust curriculum regarding a significant proportion of learners with impostor syndrome⁽⁸⁾. Medical education, therefore, needs to provide opportunities to safely understand and share doubts and experiences, a “growth mindset”, in which errors are viewed as teaching opportunities rather than failures. Thus, in secure environments, trainees share their challenges and use setbacks as teaching moments⁽⁷⁾.

Impostor syndrome can be brought on by negative self-talk, unsatisfactory grades, familial pressure, perfectionist tendencies, and coping through self-pitying humor. To avoid burnout, anxiety, professional dissatisfaction, and potentially even leaving the medical field, students who experience impostor syndrome need to acknowledge their own value and abilities, and come to the realization of their level of academic competence, diligence and commitment⁽⁶⁾.

Impostor syndrome can have a serious negative effect on relationships, educational and job opportunities, among other areas of life. When one becomes increasingly unaware of skills, work input and achievements, self-doubt spirals out of control, and the student is unable to fully experience academic and professional opportunities and workplace health⁽¹⁰⁾.

Impostor syndrome is more common than believed. Healthcare personnel are not simply experts, but also humans, with worries and shortcomings. Increased awareness will provide personal and professional growth, along with better mastery of impostor experiences^(11,12).

Physician burnout has been a major concern during the last decade. While numerous variables lead to burnout, the effects of impostorism and self-doubt have largely been overlooked. Impostorism is widespread among medical students and trainees, and it contributes to anxiety and burnout. Medical training institutions must understand the impostorism phenomenon and its impact for trainees’ mental health in the workplace. Strategies that address the impostor experience promote health and reduce burnout in medical students and medical trainees⁽¹³⁾.

Objective

We assessed the relationship of the impostor phenomenon and its components with the total academic burnout and its components among international medical students from Cluj-Napoca, Romania.

Materials and method

We assessed the international students at the “Iuliu Hațieganu” University of Medicine and Pharmacy, Cluj-Napoca, Romania, Faculty of Medicine (English section), between 27.03.2024 and 14.05.2024. The participants provided the informed consent and agreed to have their answers analyzed in the study. We included 162 participants, aged 18 to 35 years old, with median age being 23 years old, 59% females, and 74% from the urban area.

Participants’ distribution according to year of study is presented in Figure 1.
 

The Clance scale

The Impostor Syndrome Clance Scale⁽¹⁴⁾ is a 20-item questionnaire where each item is scored from 1 – not at all true, to 5 – very true, respectively, with a total score of 20 to 100. Overall, the scale identifies three aspects of impostor syndrome. The Fake component (items 3, 4, 6, 7, 8, 12, 13, 14, 17, 18 and 20) investigates self-doubt and concerns about intellect and skill. The Discount component (items 10, 16 and 19) investigates the inability to own one’s success and accept compliments for good work. The Luck component (items 9, 11 and 15) investigates the perception of task completion as due to chance or error, rather than ability^(14,15). Items 1, 2 and 5 are included in the total score, but not in the subscales⁽¹⁶⁾.

Studies on various populations identified fear of failure as an important component of the impostor experience. Albeit not classified as a separate subdimension of impostor syndrome, it is implicitly addressed in questions about self-doubt and perception of fraudulence, and profoundly influences its core elements^(17,18).

The School Burnout Inventory (SBI) Scale

The SBI scale consists of nine items that measure emotional exhaustion (four items), depersonalization (three items), and sense of personal non-fulfillment (two items). The SBI items are scored on a six-point Likert scale, from 1 = strongly disagree, to 6 = strongly agree; they provide a total score as well as dimensional scores⁽¹⁹⁾.

The statistical analysis was carried out using the Statistical Pack for Social Sciences (SPSS) version 29. The analysis of the distribution of continuous quantitative variables was performed using the Kolmogorov-Smirnov test, and parametric (Pearson) or nonparametric (Spearman) correlations were used as appropriate to test the association between continuous quantitative variables.

Results
 

Discussion

Medical students have been shown to experience significant stress because of their academic pursuits. Since undergraduate education is aimed at ensuring employment opportunities, academic strain is currently viewed as part of workplace mental health. Studying medicine is characterized by competitiveness, a lack of time for hobbies or social engagement, and schedules that require complete commitment, all of which might result in lower life satisfaction and poorer overall health than the general population^(20,21).

The current study examines the relationship of impostor syndrome and all its components, with school burnout and all its components, among international medical students studying in English.

Our study revealed a strong positive correlation between total levels of impostorism and the total burnout score in participants: the higher the levels of burnout, the higher the impostor phenomenon experienced. Other studies, with the same Clance Impostor Phenomenon Scale and a different measure of burnout, the Maslach Burnout Inventory (MBI), in a working population, provided similar results⁽²²⁾. A holistic program for high-achieving professionals (nursing, psychological science, law, engineering, finance, and medicine) identified impostorism difficulties in healthcare practitioners that require different burnout prevention strategies than the ones developed for other professional sectors⁽²³⁾.

Among the three subdimensions of impostorism, the Fake component (i.e., feeling like a fraud) exhibited the highest correlation with the Total Burnout Score in our sample. To our knowledge, there are no other studies addressing this specific issue, which is a relevant starting point for burnout prevention strategies tailored for medical students.

We found a strong positive correlation between Exhaustion and Inadequacy Burnout, respectively, and all three impostor syndrome subscales: Discount, Luck, and Fake: the higher the exhaustion and inadequacy burnout in our sample, the stronger the discount of achievements, the attribution of success to luck, and the self-perception as fake. Conversely, the Cynicism Burnout showed a low, albeit significant, positive correlation with the aforementioned impostor syndrome subscales, deeming cynicism as lower relevance contributor to burnout in medical students.

These results are supported by another study among young Arab adults, that used the Young Impostor Scale (YSI) and Maslach Burnout Inventory (MBI), which found that emotional exhaustion burnout carried the highest association with impostorism components, followed by depersonalization and low personal accomplishment⁽²⁴⁾.

Studies state that interventions for mental health in the workplace should prioritize physical and emotional strain to decrease exhaustion burnout, and then address inadequacy and cynicism by increasing students’ confidence in their work and re-engaging students with their academic commitment. This ensures a comprehensive approach to all facets of the impostor experience⁽²⁵⁾. Implementing strategies such as mentoring and task-specific individualized positive feedback could reduce this experience of feeling like a fake academically. To alleviate luck and discount experiences of impostorism, students need help recognizing and embracing their potential and their work as part of their success^(8,26).

Our study evaluated the association between the facets of impostor syndrome and age, showing a weak negative correlation of impostorism facets with age: the older medical students are, the lower the tendency to feel like a fake, to feel lucky academically and to discount successes. However, the association of age with discount is not significant, while the low correlation of age with the other two facets of impostorism indicates that age is not a direct but a contextual factor in the impostor experience. This indicates that universities and academia should stop normalizing certain feelings of impostorism as part of being young/a beginner, and stop expecting students to outgrow them in later years. In this respect, studies show that personal experience and support are more important predictors than age in the degree of experienced impostorism, especially in student populations⁽⁸⁾; more advanced students gradually realize how little they have mastered thus far from the required skills and knowledge, therefore curbing the decrease of impostorism with age in student populations⁽²⁷⁾.

When impostor syndrome is not addressed, the fear of failure may deter those affected, leading to significant hesitation regarding potential opportunities. The pressure within the medical profession to attain extensive knowledge can trigger feelings of anxiety and self-doubt, particularly when self-imposed performance standards are excessively high. The faculty of medicine embodies a transformative process fundamental to the training of future doctors. It facilitates the transfer to a more challenging environment, which requires the development of effective adaptive strategies⁽²⁸⁾.

Burnout is notably prevalent among medical students, highlighting a critical need for recognition and management. Training years result in the highest levels of burnout for medical trainees, with severe implications such as suicide ideation. Risk of burnout grows as workload increases, indicating a critical need for effective and thorough supervision of future physicians^(29,30).

The limitations of this study include a nonhomogeneous distribution by years of study and a relatively short response period for the questionnaire. Also, the cross-sectional design does not allow the tracking of certain variables over an extended period. Also, more in-depth studies could specifically investigate if and how the pandemic has played a role on the impostor syndrome for medical students, undergraduates in general, and medical trainees. Additional parameters, such as depression, exposure to trauma, perceived stress and self-harm, can bring more clarification.

Considering the findings of this study, several avenues for future research emerge. Further prospective studies could explore the relationship between burnout and impostor syndrome to understand whether interventions for a specific type of burnout directly impact the impostor syndrome levels, as well as investigating additional factors that may influence these relationships, such as social support and personality traits. Also, prospectively measuring how the impostor experience is influenced by more awareness of progress in learning via 360 degrees feedback (self-evaluation of specific progress milestones and specific performance evaluation from peers, teachers, not just overall grades) may shed light on how impostorism can be tackled by effective progress assessments. Addressing all these gaps will be crucial for advancing our understanding of impostorism in medical trainees.

Conclusions

The level of burnout has a relevant direct association with the overall self-perception as an impostor among international medical students.

As burnout levels increase in international medical students, so do the self-perception of being a fraud, the minimization of achievements, and the belief that success is due to luck.

The level of the component of burnout known as emotional exhaustion has a relevant direct association with the overall self-perception as an impostor among international medical students.

The level of the component of burnout known as emotional exhaustion has a relevant direct association among international medical students with the three facets of self-perception as an impostor: feeling like a fake, discounting positive evaluations, and feeling that success is due to luck, respectively. The emotional exhaustion levels, more specifically, have the strongest direct association with feeling like a fake.

Autori pentru corespondenţă: Dana-Cristina Herţa E-mail: dana_cristina75@yahoo.com

CONFLICT OF INTEREST: none declared.

FINANCIAL SUPPORT: none declared.

This work is permanently accessible online free of charge and published under the CC-BY.