This study examined the incidence and severity of impostorism in third-year medical students as they transitioned from the preclinical to clinical phases of training.
A cross-sectional study was conducted in third-year medical students (N=215). Respondents completed a voluntary, anonymous, 60-item survey that included the Clance Impostor Phenomenon Scale and the Perceived Stress Scale. Student’s-t, Mann-Whitney, and Chi-Square tests and Pearson correlation were used to determine differences between subgroups of students and relationships between instruments scores and demographic parameters.
Fifty-nine percent of students responded with N=112 (59% female) completing at least one instrument. The mean impostor score was 63.0 ± 14.6 (moderate-to-frequent impostor feelings) and was 9% higher in females (U=1181, p = .046). Perceived Stress scores for females were 17% higher than males (t(109)=2.87, p=.005). Females had lower United States Medical Licensing Examination (USMLE) Step 1 scores (t(107)= 3.06, p=.003). Impostor and perceived stress scores were correlated for males (r(46)=.47, p=.002) and females (r(64)=.54,p<.0001). Impostor and USMLE Step 1 scores were negatively correlated for males (r(45) =-.32, p= .034) but not females (r(63) = -.11, p=.40).
These findings demonstrate the intercorrelation between impostorism and stress in male and female medical students and raise interesting questions regarding the contributions of gender and other factors involved with medical training.
Impostor phenomenon is the experience of doubting one’s accomplishments and abilities despite evidence to the contrary and fearing exposure as an “impostor”.
Impostorism affects nearly half of female and one-fourth of male medical students.
Impostor feelings are most likely to occur during periods of transition, such as beginning a career or moving between phases of a career.
The purpose of this study was to examine the incidence and severity of impostorism specifically in third-year medical students as they experienced the stressful early phases of their clinical training. Differences between subgroups of students were assessed. Relationships between instrument scores and demographic parameters were also determined to identify attributes potentially contributing to impostorism. Noteworthy gender differences and intercorrelations were observed and are reported here.
This study was conducted under the authority of the University of Kansas Medical Center Office of Research Compliance who reviewed the study protocol and monitored study activities to ensure that appropriate steps were taken to protect the rights and welfare of humans participating as research participants (STUDY #00142155). Informed consent was obtained from all participants prior to participation. Anonymous, private surveys were used to minimize the risks of participation. The investigators did not serve as instructors for the students being surveyed. The choice to participate was voluntary and had no impact on the students’ standing in their educational program. Data was accessible only to the research team. The participation incentive was designed so that no individual benefitted personally from participating. There were no physical risks to the participants. Psychological risks were minimal and consisted of awareness of symptoms of impostorism, stress, and burnout. Participants were instructed that they were not required to complete any items that made them feel uncomfortable.
Third-year medical students (N = 215) of the University of Kansas School of Medicine class of 2020 participated in this study. The University of Kansas School of Medicine had a traditional four-year program in which students underwent two years of preclinical training, consisting of a lecture-based integrated basic science curriculum with some clinical skills experiences, followed by two years of clinical training. Students take the United States Medical Licensing Examination (USMLE) Step 1, which covers the foundational sciences, at the end of Year 2 and must pass the exam before beginning their clinical training. Clinical training began with six required eight-week rotations to which the students were randomly assigned. Students were located on three campuses in Kansas City, Wichita, and Salina (65%, 35%, and 0% of respondents, respectively). Most students completed all four years on the same campus; however, a subset of students (19% of respondents) completed the preclinical phase in Kansas City and then moved to Wichita for the clinical phase.
A voluntary, anonymous, 60-item survey was administered in October-November of the 2018 Fall semester. This time window for data collection was selected so that students would be in the early phase of their clinical training but would have completed at least one clinical rotation.
Data were collected and managed by the authors using REDCap (Research Electronic Data Capture) tools
Impostorism, stress, and burnout were assessed using validated instruments. The survey consisted of the instruments described below, as well as demographic items (e.g., age, race, gender, entering Medical College Admission Test score, medical Year 1-2 grade point averages (GPA), etc.). It required roughly 20 minutes to complete. Participation was incentivized by a contribution to the class fund if a specified response rate was achieved.
The Clance Impostor Phenomenon Scale
Stress was measured using the Perceived Stress Scale
Impostor score in third-year medical students. The mean in the box plot is indicated by the dotted line. N = 112 for all students; 46 for males, 66 for females *p=.46 by Mann-Whitney test (U = 1181).
Burnout was assessed using a 2-item instrument (licensed from Mind Garden) developed for and validated in medical professionals.
Data were analyzed using SAS statistical software (version 9.4) and Instat 3. Eight respondents omitted a response to one item on the Clance Impostor Phenomenon Scale (a different item for each respondent). The total impostor score for these eight individuals was calculated by multiplying their score from the 19 completed items by 1.05263 and rounding to the nearest whole number.
A preliminary analysis determined no effect of campus; consequently, the campus was not used as a variable in the present analyses. Differences in responses by gender were determined by Student’s-t, Mann-Whitney, or Chi-Square tests, as appropriate. A non-parametric test was used for data that failed a test for normality. Relationships between scores for the individual instruments and demographic parameters were determined by Pearson correlation.
Perceived Stress score in third-year medical students. The mean is indicated by the dotted line. N = 111 for all students; 46 for males, 65 for females. *p = .005 by Student's t-test (t(109) = 2.867).
A total of 127 of 215 (59%) students surveyed responded with N = 112 completing at least one instrument and N= 111 completing all three instruments. The demographic characteristics of respondents are summarized in
Variable | Class Mean (N%) | Respondents N | Total Mean (N%)/ Mean±SD (Range) | Male (N=46) Mean (N%)/ Mean±SD (Range) | Female (N=66) Mean (N%)/ Mean±SD (Range) | Male v. Female | ||
---|---|---|---|---|---|---|---|---|
Test* | df |
|
||||||
Total | 215 | 112 | ||||||
Male | 110 (51) | 46 (41) | ||||||
Female | 105 (49) | 66 (59) | ||||||
Age | 25.7±3 | 110 | 25.9±3 (23-44) | 26.5±4 (24-44) | 25.5±2 (23-34) | t = 1.56 | 108 |
|
Race | 112 | |||||||
Caucasian | 172 (80) | 94 (84) | 40 (87) | 53 (81) | c2 = 7.3 | 3 |
|
|
African - American | 7 (3) | 2 (2) | 1 (2) | 1 (2) | ||||
Asian | 24 (11) | 8 (7) | 5 (11) | 3 (5) | ||||
Other | 9 (4) | 8 (7) | 0 (0) | 8 (12) | ||||
Hispanic | 13 (6) | 9 (8) | 4 (9) | 5 (8) | c2 =.036 | 1 |
|
|
Undergraduate GPA | 111 | 3.8±0.24 (3-4) | 3.7±0.27 (3-4) | 3.8±0.22 (3-4) | t = .51 | 109 |
|
|
Composite MCAT | 507±6.1 | 105 | 508±5.5 (493-525) | 508±5 (500-518) | 507±6 (493-525) | t = .91 | 104 |
|
GPA Year 1 | 3.39±0.47 | 103 | 3.4±0.44 (2-4) | 3.5±0.44 (2-4) | 3.4±0.45 (2-4) | t = .87 | 101 |
|
GPA Year 2 | 3.36±0.53 | 103 | 3.4±0.45 (2-4) | 3.5±0.43 (2-4) | 3.4±0.47 (2-4) | t = .48 | 101 |
|
USMLE Step 1 Score | 225±19 | 109 | 228±18 (146-264) | 233±16 (146-264) | 225±15 (194-256) | t = 3.06 | 107 |
|
Assigned Campus | Kansas City | Wichita | Salina | |||||
Preclinical | 175/32/8** | 111 | 94 (84) | 17 (15) | 0 (0) | |||
Clinical | 140/67/8** | 111 | 71 (64) | 37 (34) | 0 (0) |
Data are presented as M±SD with ranges for continuous variables and frequencies with percentages for categorical variables.
*Statistical testing applied Student’s-t test or Chi Square test. p < .05 is considered significant. **Number of students by campus: Kansas City/Wichita/Salina
Abbreviations: GPA – grade point average, MCAT - Medical College Admission Test, USMLE – United States Medical Licensing Examination
The distribution of impostor scores is shown in
The overall mean perceived stress score was 18.5 ± 5.5 (
Several intercorrelations were identified between study variables that differed by gender. Impostor and perceived stress scores were strongly correlated in females (r(64) = 0.54, p < .0001) and moderately correlated in males (r(46) = 0.45, p = .002) (
No significant relationships were identified between impostor score and age, race, undergraduate grade point average, composite Medical College Admission Test score, Years 1 and 2 grade point averages, burnout, or depersonalization for either gender (data not shown).
Relationship between impostor and perceived stress scores in male (A) and female (B) third-year medical students. Impostor and perceived stress scores were strongly correlated in females (r(64) =.54, p less than .001) and moderately correlated in males (r(46) = .47, p = .002) by Pearson correlation. n = 45 for males, 65 for females.
Relationship between United States Medical Licensing Examination (USMLE) Step 1 score and impostor score in male (A) and female (B) third-year medical students. A moderate negative correlation was found for impostor score and UMSLE Step 1 score in males (r(44) = -0.32, p = .034), but not in females (r(63) = -0.11, p = .40). n = 45 for males, 63 for females.
This cross-sectional assessment of impostorism in medical students examined a specific time point in medical training, encompassing the transition and early portion clinical training occurring after the completion of at least one required 8-week clinical rotation. This is a notably stressful period and is associated with a decrease in confidence.
Notable relationships between study factors, as well as gender differences, were observed. First, females reported significantly more stress than males (
Second, females had lower USMLE Step 1 scores than males (
This study is limited by its cross-sectional design using self-reported data from a single class at a single medical school with a response rate of 59%. Accordingly, the findings may not generalize to other times, schools, educational programs, or types of students. Respondents may have different characteristics from those who declined to complete the survey. The analyses did not control for the specific clinical rotations completed by each student. Finally, causal relationships cannot be established from this observational study design.
These findings demonstrate significant impostorism in medical students during the early phase of clinical training and indicate noteworthy differences between male and female students. These observations raise interesting questions regarding the contributions of gender and other factors involved with medical training on academic performance and identity formation in medical students. Future studies (e.g., longitudinal and multiple cohorts) are required to confirm the observations reported here and establish causal relationships between factors, such as the USMLE Step 1 exam, and impostorism and stress in during medical education. A greater understanding of these effects and relationships may inform efforts to foster student wellness and enhance the experience of students as they negotiate the transition from the preclinical to clinical phases of their training.
The authors thank Drs. Giulia Bonaminio and Mark Meyer for their support and assistance in the execution of this project. Supported by the University of Kansas School of Medicine Academy of Medical Educators and NIH CTSA Award UL1TR002366.
The authors declare that they have no conflict of interest.