To describe levels of burnout and impostor syndrome (IS) in medical students, and to recognize demographic differences in those experiencing burnout and IS.
Anonymous survey administered online in 2014 that included demographic data, the Maslach Burnout Inventory and an IS screening questionnaire. Main outcome measures were level of burnout, and presence or absence of imposter syndrome. The presence of IS and burnout components were analyzed across age, gender, race, year of training, intention to pursue fellowship training, and greater than one year of work experience outside of medicine using chi-squared tests. The association between burnout and IS was also compared using chi-squared tests.
One hundred and thirty-eight students completed the questionnaire. Female gender was significantly associated with IS (χ2(3)=10.6, p=0.004) with more than double the percentage of females displaying IS than their male counterparts (49.4% of females versus 23.7% of males). IS was significantly associated with the burnout components of exhaustion (χ2 (2)=5.9, p=0.045), cynicism (χ2(2)=9.4, p=0.004), emotional exhaustion (χ2(2)=8.0, p=0.018), and depersonalization (χ2 (2)=10.3, p=0.006). The fourth year of medical school was significantly associated with IS (χ2(3)=10.5, p=0.015).
Almost a quarter of male medical students and nearly half of female students experience IS and IS was found to be significantly associated with burnout indices. Given the high psychological morbidity of these conditions, this association cannot be ignored. It behooves us to reconsider facets of medical education (i.e. shame-based learning and overall teaching style) and optimize the medical learning environment.
Physician burnout has received a considerable amount of attention in recent years. Medicine self-selects for individuals who are driven, competitive, and able to endure years of intense schooling and high expectations. Unfortunately, these qualities also contribute to the development of burnout, the ramifications of which go beyond the individual experiencing it. Among residents, burnout is associated with absenteeism and, more disturbingly, medical errors and self-reported delivery of suboptimal care.
A related, but less investigated entity which has gained recent popularity in the lay press and scientific literature is impostor syndrome (IS) or impostorism.
IS has several potential implications for medical education. Those suffering from IS are less likely to speak up or volunteer answers and information than their unaffected peers. This may lead to innate differences in learning style and a subsequent need to tailor curriculum to take into account the large proportion of learners with IS. Furthermore, the literature largely supports a higher levels of IS in women.
IS, especially in relation to burnout, remains an area in need of further investigation among the medical student population. This pilot study seeks to explore IS and burnout in medical students and the associated comorbidity of burnout.
This pilot study’s protocol was reviewed and approved with exempt status by the State University of New York – Upstate Medical University Institutional Review Board. This study was received and determined to be of exempt status by the SUNY-Upstate Medical University Institutional Review Board because of its educational nature and the fact that it exposed participants to no risk. From November 2013 to March 2014, medical students from a single United States medical school received an e-mail invitation to participate in an anonymous, self-administered, web-based survey. One hundred and thirty-eight medical students completed this pilot survey (response rate of 20%). Responses were received from students across all training years. Demographic data is shown in
Variable | Respondents N (%) | |
---|---|---|
Age | ||
18 – 24 | 59 (42.75) | |
25 – 30 | 69 (50) | |
31 – 35 | 5 (3.62) | |
36 – 40 | 2 (1.45) | |
41 – 45 | 1 (0.72) | |
46 – 50 | 2 (1.45) | |
Female | 77 (56.2) | |
Race | ||
Black | 2 (1.46) | |
White | 116 (84.67) | |
Latina/o | 4 (2.92) | |
Asian | 16 (11.68) | |
Native American | 1 (0.73) | |
Multiracial | 4 (2.92) | |
Year of Training | ||
1st year | 41 (29.71) | |
2nd year | 29 (21.01) | |
3rd year | 34 (24.64) | |
4th year | 34 (26.64) | |
Plans to pursue fellowship training | ||
Yes | 55 (39.86) | |
No | 16 (11.59) | |
Undecided | 67 (48.55) | |
Worked outside of medicine > 1 year | ||
Yes | 67 (48.91) |
Students in all levels of training responded at roughly similar rates. There was a slight female preponderance of responses (56.2%). The vast majority of students identified as Caucasian (84.6%) with Asian being the next most common race (11.68%). Nearly half of medical students in our cohort have spent at least one year working in a field outside of medicine. Future specialty choice was highly variable, with many students undecided.
Demographic data collected from participants included age range, race, gender, year in training, desired specialty, and if there had been a gap in educational training for work in a field outside of medicine for greater than one year.
The Young Impostor Scale (YIS) was used to dichotomously assess for the presence or absence of IS. The YIS is an eight item instrument used to assess for impostor-like feelings (e.g. do you secretly worry that others will find out that you’re not as bright and capable as they think you are?” See
As described by Maslach et al, the Maslach Burnout Inventory - Human Services Survey was used. This questionnaire evaluates the frequency with which respondents experience feelings across the domains of emotional exhaustion, depersonalization, and personal accomplishment.
All statistical calculations were performed using SPSS Version 17 software (IBM Corporation, Armonk, NY, USA). Data was automatically collected by the internet-based survey software. The data were then imported into SPSS for analysis. The presence of IS and burnout components were analyzed across age, gender, race, year of training, intention to pursue fellowship training, and greater than one year of work experience outside of medicine using chi-squared tests. The association between burnout and IS was also compared using chi-squared tests. Significance was set at p < 0.05.
Female gender was not significantly associated with burnout components. However, female gender was significantly associated with IS (χ2(3) = 10.6, p = .004), with more than double the percentage of females displaying IS than their male counterparts (49.4% of females versus 23.7% of males).
There was a trend towards significance between race and IS. The groups that make up the majority of medical students – Asians and whites – have a 30% rate of IS, versus 72.7% in all other races (χ2(3) = 6.87, p = .057). The majority of students were undecided with respect to their specialty, precluding analysis of specialty choice on burnout or IS.
IS was significantly associated with multiple burnout components. These included exhaustion (χ2(2) =5.9, p=0.045), cynicism (χ2 (2) =9.4, p=0.004), emotional exhaustion (χ2(2)=8.0, p=0.018), and depersonalization (χ2 (2) =10.3, p=0.006), see
Burnout Components | Degree of Burnout N (%) | |||
---|---|---|---|---|
High | Moderate | Low | ||
Depersonalization* | ||||
IS | 14 (27) | 18 (35) | 20 (38.5) | |
No-IS | 7 (8.1) | 28 (33) | 51 (59) | |
Personal Accomplishment | ||||
IS | 8 (15) | 19 (37) | 25 (48) | |
No-IS | 16 (19) | 25 (48) | 50 (58) | |
Emotional Exhaustion* | ||||
IS | 25 (48) | 19 (37) | 8 (15) | |
No-IS | 23 (26) | 35 (40) | 28 (32) | |
Professional Efficacy | ||||
IS | 1 (2) | 4 (8) | 47 (90) | |
No-IS | 0 (0) | 5 (6) | 81 (94) | |
Exhaustion* | ||||
IS | 40 (77) | 12 (23) | 0 (0) | |
No-IS | 50 (58) | 33 (38) | 3 (3.5) | |
Cynicism* | ||||
IS | 36 (69) | 15 (29) | 1 (1.9) | |
No-IS | 15 (29) | 46 (54) | 0 (0) |
*The burnout component is significantly associated with IS (p<0.05).
This pilot study sought to explore IS and burnout in medical students. In our survey of 138 medical students, we found that female gender was significantly associated with IS. IS was significantly associated with burnout; students with IS had significantly increased levels of exhaustion, emotional exhaustion, cynicism, and depersonalization. Clearly, these are not the traits medical education seeks to foster.
The results of our pilot study are supported by prior published studies. Oriel et al similarly found that gender impacted IS with 41% of female, and only 23% of male, family medicine residents experiencing IS.
Prior studies have not shown an association between program year and IS - indicating that impostorism may be a static behavioral trait.
In contrast to IS, burnout in medicine has received much greater attention. Burnout is most commonly defined as a triad of emotional exhaustion, depersonalization, and diminished feelings of personal accomplishment. The typical picture of burnout mimics depression and is all too familiar in medicine: fatigue, inability to concentrate, insomnia, irritability, and feeling as if one is “just going through the motions”.
The psychological comorbidities of IS and burnout cannot be ignored. Henning et al discovered that 30% of medical, dental, nursing, and pharmacy students met IS criteria and suffered increased psychological distress.
Limitations of this study include that it is a self-administered, survey based, convenience sample of medical students at one United States medical school with a relatively small sample size. Significant associations may change with a larger sample. The self-reporting and self-selection of participants introduced bias with many survey items subject to social desirability response bias. We did try to minimize this bias with the anonymous nature of the survey. Additionally, our results are similar to those presented by other authors and it has been previously shown that the MBI is resistant to the threat of social desirability bias.
Assuming the medical students surveyed in our pilot study are representative of medical students in the United States, we submit that optimization of the training paradigm to take into account IS and burnout is needed. Ensuring the wellbeing of our future physicians must be a priority. The core of medical education essentially remains unchanged since the Flexner report in the early 1900s. Specific suggestions have been made such as regular, timely, and positive feedback from instructors; regular feedback is now a metric required by the ACGME. However, with the large numbers of trainees struggling with IS, burnout, and the associated psychological comorbidities, a shift away from the traditional “shame-based” learning and “pimping” to more of an open and consistent educational dialogue may be needed. Additionally, given the high numbers of medical professionals experiencing psychological stressors such as burnout and IS, it is important that attention also be paid to discovering ways to counter these negative influences and enhance wellness. For example, professional development programs, beginning early in medical training, may be of benefit to help foster development of overall self-efficacy.
Future research will focus on identifying medical students at risk for burnout, IS, and associated psychosocial comorbidities, while identifying ways to ameliorate the negative impact of these conditions.
IS exists in a significant percentage of medical students and appears to peak in the fourth year of medical school. Additionally, it is associated with multiple burnout indices and, likely, psychological distress. Further discussion regarding medical education paradigms in light of high levels of burnout and IS is needed.
The authors declare that they have no conflict of interest.
Appendix 1. Young Imposter Syndrome Quiz (“Yes” or “No”)