August 3, 2023 • 30 mins
In this episode, Dr Dante Yeh is joined by Lola Fayanju, MD, MA, MPHS, FACS, from The University of Pennsylvania, Philadelphia, PA. They discuss Dr Fayanju’s recent study on imposter syndrome, an internalized sense of incompetence and not belonging. The study found that female physicians were more likely to experience imposter syndrome than male physicians, regardless of specialty or leadership role. While several identity-based gaps persist in leadership, imposter syndrome among racially minoritized groups may not be a significant contributor.
Disclosure Information: Dr Yeh receives author royalties from UpToDate, advisory panel/training honoraria from Takeda Pharmaceuticals, and advisory panel honoraria from Baxter, Eli Lilly, and Fresenius Kabi.
Support: Dr Fayanju is supported by National Institutes of Health award 7K08CA241390-03.
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(00:01):
Welcome to The Operative Word,
a podcast brought to you by the
Journal of the American College of
Surgeons.
I'm Dr. Jamie Coleman.
And throughout this series, Dr.
Dante Yeh and I will speak with
recently published authors about the
motivation behind their latest
research and the clinical
implications it has for the
practicing surgeon.
(00:22):
The opinions expressed in this
podcast are those of the
participants and not necessarily
that of the American College of
Surgeons.
Welcome to The Operative Word, a
podcast from the Journal of the
American College of Surgeons.
I'm Dr. Dante Yeh, one of your
co-hosts for this series.
In this episode, we'll be taking an
in-depth look into the current
article, Leadership and Imposter
(00:44):
Syndrome in Surgery.
I'm honored to be joined by the
senior author, Dr. Lola
Fayanju, MD, MA, MPHS, FACS, Chief
of Breast Surgery at the University
of Pennsylvania.
Dr. Fayanju, thank you for joining
me today. Before we begin, do
you have any potential conflicts of
interest to disclose?
(01:05):
I was funded by a
K08 award from the National Cancer
Institute during the time that the
study was being completed.
Great. Thank you.
And congratulations.
Why don't we start by having you
give us a brief summary of your
study and tell us about your main
findings.
So my study team and I conducted
a cross-sectional survey that was
(01:26):
administered to physicians across
the United States over approximately
six months in
2021. So really during the height of
the pandemic, and I really
had a fantastic team,
multi-disciplinary, consisting of
medical students as well as
internists, as well as surgeons.
And we were actually asking
a number of questions about
(01:47):
the types of factors that are
associated with who goes into
medicine, who holds leadership
positions in medicine, and people'strajectory
through medicine. And the question
about imposter syndrome specifically
was a subset of this larger
survey.
And in this survey, we
specifically asked individuals,
first of all, whether or not they
were in leadership.
And then we sought to find out
(02:09):
amongst those who were in leadership
and not in leadership, what
factors were associated with being
in leadership as well as what
factors were associated with their
experiencing imposter
syndrome.
And, imposter syndrome, as
many of you will have heard
is an internalized sense of
incompetence or not belonging.
It is something that's often been
ascribed to individuals from
(02:30):
minoritized backgrounds in
whatever situation in which they
find themselves the minority.
So it might be women in the field
of surgery as there are fewer women
in the field of surgery.
It might be people of color in the
field of surgery. Likewise, where
there are fewer people of color
and it might be people from the
LGBTQ community, for example, in
more heteronormative circumstances.
And so the idea is that imposter
(02:51):
syndrome is something that
individuals within these minoritized
groups or groups that are in some
other way marginalized feel,
and that does not reflect their
actual ability or skillset,
but nonetheless reveals
their feeling that they don't belong
to a larger whole and that they
don't feel frankly worthy
of being part of that whole.
And that might contribute to their
(03:12):
ability to be full participants
in that group and to achieve as
fully when they are ascribed
leadership roles or tasks
or other types of responsibility
as part of that group membership.
And in the end, we
had approximately over
2000 people, a combination
of retired and attending physicians,
(03:32):
mainly attending physicians,
who responded to this portion of
our our survey.
And what we found is that
overall women were more likely
to experience imposter syndrome than
men quite significantly.
But we did not find this association
when we looked at people from
racially and ethnically minoritized
backgrounds, and we did
(03:53):
not find that this differed even
when they were women,
for example. So the intersection
of being a racial ethnic minority
and being a woman and we didn't find
this, whether or not people were in
leadership roles or not.
And so our conclusion was that it's
interesting to find that female
physicians are more likely to
experience imposter syndrome than
men, regardless of specialty.
(04:13):
As I said, we went across a number
of different specialties and had
also a multidisciplinary research
team and also regardless
of leadership status, but that when
we looked at racially and
ethnically defined identities, we
did not see an association
or a higher prevalence of imposter
syndrome in minoritized
groups.
And the reason this is fairly
(04:34):
important is because people have
often used imposter syndrome
as a reason for why there might
be a lower
or rather a slower climb and
participation of minoritized
individuals in majority
groups. So the reason there might be
a slower gain amongst black men,
for example, in having proportional
representation amongst physicians
(04:56):
or slower gain in whatever other
type of group, that that might be
because of internalized imposter
syndrome. What our findings suggest
is that actually we need to look
elsewhere. This is not about some,
frankly, you know,
internalized sense of incompetence
or not belonging.
We have to look for other reasons
for why certain groups are still not
represented at the rates they should
be in our field of
(05:18):
medicine and within surgery as well.
Great. Well, thank you for that
brief summary.
There's a lot to unpack here,
and I was taking down some notes.
So it sounds to me that
your study concludes that
female physicians were more likely
than male physicians to experience
the imposter syndrome or
(05:39):
to report that they had the feelings
of imposter syndrome on this survey,
regardless of specialty
or leadership role.
However, when you looked at racial
background, that that was not the
case. Am I summarizing it correctly?
Correct.
Do you know, is this
phenomenon being shown
(05:59):
in other fields or is it unique
to just medicine?
So unfortunately, we have seen
that there is imposter syndrome
seen frequently
in other fields outside of medicine
among women.
And we do typically see this also
with regards to racial and ethnic
minorities, which is why our
findings specifically
(06:21):
where there is divergence between
those who are part of were
female versus those who were
racially and ethnically minoritized
physicians.
We were surprised to see that split.
While typically we've seen that
that is observed more in both
of those groups and other fields,
such as business or
other types of non-healthcare
fields.
(06:42):
And again, it's interesting,
it makes us just have to question
again more whether
we are looking at the right types of
things.
You know, a lot of people have
concerns about the term imposter
syndrome for a number of reasons.
One, it
ascribes the lack of belonging or
the lack of membership or
participation by a particular
(07:04):
group or particular individuals from
groups as seeming like
the fault of those individuals
versus the fault of the majority
group to which they are being, from
which they're being excluded.
And so, you know, imposter syndrome
has in some level is questioned
as a as a real entity that maybe
it's something that's actually being
imposed on people that's
internalization of an unfair
assessment by others versus
(07:25):
something that results from any type
of lack or self-perceived
lack by the individuals who are
reported as having it.
And so I think it's important
that even though we you know, we
asked about this and we saw this
interesting finding, it just makes
us, again, question the extent to
which we have non-diverse
specialties, non diverse fields.
How much are we ascribing the blame
(07:46):
for that, either implicitly or
explicitly to the individuals who
are being excluded versus they're
not participating?
How much are we really taking on the
burden of our of our field
versus blaming individuals for not
feeling like members of a field
that's been very homogeneous for a
very long time?
Yeah, that that's that raises a lot
of questions, which I think at this
(08:08):
generic or general very
broad view from the survey that you
have, it's going to be impossible to
to answer those questions until we
drill down at a more granular
level.
You mentioned earlier that one
potential way that
this can manifest is that if an
individual has the sense
of imposter syndrome, they may be
(08:30):
less likely to participate
and that may
hold them back or that may adversely
affect their promotions and
their career track.
Are there any other like mechanisms
of action that that have been
tested or or proven,
for example, in other fields that
that could connect the dots from
this individual has the sense
(08:51):
of imposter syndrome to
this individual is now
underrepresented
in leadership positions.
So there has been some evidence
that because impostor syndrome
is frequently associated with
anxiety and burnout, and I want to
emphasize associated with so
we can't be sure whether impostor
syndrome is the kind of thing that
(09:11):
results in people who already have a
predisposition for anxiety
or susceptibility to moral
injury that can be experienced by
people in health care, or
whether or not imposter syndrome
leads people to having those
experiences. So I just want to
emphasize that.
But nonetheless, since we know that
there is an association between
imposter syndrome and anxiety and
(09:31):
burnout, we have seen that
interventions that target,
you know, any of those things can
have an effect on the other.
So, for example, there's been
evidence that coaching, professional
coaching can actually have a
significant effect on improving
imposter syndrome, but
can also frankly improve the
likelihood of someone developing
other skill sets that lead to
(09:52):
professional advancement.
Right. So it's a little bit tricky
because imposter syndrome is in
itself something
that has a definition, but that
may manifest itself differently in
individuals, even within
different fields that
and then the interventions that are
used for imposter syndrome
may also have
an impact on
(10:14):
other characteristics also
associated with imposter syndrome.
So it's hard to isolate, you know,
what the cause and effect is
as regards to the intervention.
But nonetheless, it seems that
coaching as well as
interventions that specifically
target wellness, which is supposed
to, all of these are supposed to
help peer mentorship is
actually supposed to be very
(10:34):
important in terms
of potentially helping individuals
see that they are not different.
And then thinking beyond the
individual work and thinking more
about systemic interventions,
really
making it clear from an
institutional level
that someone belongs by the simple
(10:54):
act of making sure they're being
paid at the same level as
their majority peers, and
that they know that.
I think one of the things a lot of
women in particular experience is
this concern
that they might be being paid less
than their male peers, only to often
have that verified when they
actually directly ask people.
(11:14):
But when there's public
knowledge of salaries, which is
something that a lot of public
institutions have to do,
but that also some private
institutions choose to do
as part of moves towards equity
and avoiding kind of pay
discrepancies by gender and by race
ethnicity, that that
is thought to be potentially a way
which to assure people we really
(11:36):
do value as much as your, you know,
your your majority peers that
we are showing you that in dollars
and cents, not just in words.
And so I think that that is one way
we can do that.
One way I would also imagine is
that we know that the way in which
we value people, not just dollars
and cents, but also in terms of the
kinds of things we ask people to do.
(11:57):
We know that, you know,
women in particular, but
also people of color often do a lot
of the housekeeping work of
departments in the housekeeping work
of divisions, the kind of
lubricating tasks that make
divisions and departments run work
and feel like good places to be, but
then often are rewarded with or
translate into promotion.
(12:18):
And so if we disproportionately
give those individuals
the types of
jobs and assignments,
like, you know, Vice chief of
wellness or vice chief
of
party planning, I'm not really
saying that, you know, the kinds of
positions that we know, again,
do make everyone enjoy being
(12:39):
at work much more, but are not going
to make their way to the COAP
committee, that is the committee for
advancing and promotion, then
that doesn't show that you really
believe those people belong there in
the same way that the vice chair of
research might belong there, or the
vice chair or the Chief of
Vascular Surgery belongs there,
doesn't show that you really value
them the way that you value people
(13:00):
who are more likely majority and
more likely to hold the types of
roles that are objectively seen as
vital and important for the
department.
That's an excellent point, which I
had not even considered.
So. So thank you for that.
Your your study focused on
individuals who are holding
leadership positions in medicine.
(13:21):
Do you think that the
prevalence of imposter syndrome
is equally
widespread in in
physicians who are not in leadership
positions?
Oh, I mean, there's evidence to
believe that it's more so that, you
know, to become a leader means that
you you either didn't have
imposter syndrome or managed to
(13:41):
suppress it quite effectively
in order to achieve the status one
now holds. And so
I think what's notable is that when
you see this difference in
women, these are women
who have imposter syndrome and made
it anyway. So, you
know, they shattered the glass
ceiling while carrying this very
heavy burden.
And so I think that that says a
(14:03):
lot again about the fortitude
and the resilience of individuals
who even while feeling that they
might be less than persevered
nevertheless.
And what I think is important is to
realize that if we don't see
imposter syndrome
in the racially minoritized
individuals who we saw amongst
leadership here, it may be because
(14:23):
you have to be someone who
already really has
a deep sense of belonging
to even aspire to and achieve
leadership. If you are from a
racially minoritized background, you
know this survey was part of,
as I mentioned, a larger survey.
We also ask questions about the
likelihood of your whether or not
you had a family member in medicine.
(14:44):
And I think about that all the
time. I think it's really striking
when you look around your med school
class and realize how many people
have parents in medicine, sometimes
grandparents in medicine, and how
much more that will affect your
ability to feel like you belong
there than if you're first
generation.
And so that is to say that I think
even amongst the women and
(15:04):
the racial, ethnic minority
individuals who are in medicine,
there is some belief and that's
something that will hopefully emerge
when we when we actually share this
data from the larger survey with
the world, that it
does matter that you have
external and internal
sources of resilience that confirm
for you that you belong there, even
(15:26):
if you have other messages coming
at you that suggest that you do not.
And so that is to say that it might
be that the types of racial and
ethnic minorities who are becoming
leaders are imbued and
buoyed by other types
of resources that are not
perceptible and that are unmeasured,
but nonetheless sustain them and
(15:46):
prevent imposter syndrome from
rearing its ugly head, even when
you might expect it would.
So it sounds like we have a little
bit of a selection bias in
this particular study and
we may be under, well, we're
definitely underestimating
the prevalence of imposter syndrome
in medicine.
I strongly suspect so.
You know, I think, you know, even
(16:09):
having the ability to respond to a
survey, as we know, people who are
miserable don't respond to surveys,
people who feel like they're not
succeeding, don't respond to
surveys. So even though this was
admit, you know, this was sent to
thousands and thousands of
physicians across the country,
hardly anyone is going to respond if
they feel like they're really
struggling.
And that's one of the challenges of
conducting survey research, of
course.
(16:29):
But nonetheless, I think the fact
that we saw a signal says a lot.
Yeah, and that's a great segue.
I had a couple of questions about
the actual execution
of the survey.
I noticed that in
the methods that you sought
professional guidance
from a survey expert,
which I haven't
(16:50):
seen very commonly, but
after reading this study,
I thought it was great.
Can you can you talk to us a little
bit more about what did this survey
expert recommend and how did you
refine your methods based on their
input?
So I have a masters
in Population Health Sciences and
I have done qualitative work
(17:11):
and received qualitative training.
But.
I don't have a doctorate in
ethnography or I don't
regularly do, you know, grounded
theory as part of my routine work.
I don't conduct surveys or perform
psychometric work in my everyday
life. And so I
have the humility to realize that
I need to
(17:32):
often make sure that we're doing
this kind of thing correctly so.
So when I offer this advice
to others who might be interested in
conducting or creating a survey,
typically you want to work with
someone who or people who have that
kind of expertise.
We work with the Odum Institute at
the University of North Carolina,
which is a nationally,
if not world renowned site
(17:53):
for qualitative
research, education
and implementation.
And worked with them to review our
survey to make sure that
as we were setting up our questions,
we weren't necessarily priming
people's responses based on the
order in which the questions were
placed and the language
with which they were written.
(18:14):
In addition, you typically want to
do kind
of a test group first where you make
sure that the questions make sense
and they're kind of not
misinterpreted within the initial
pilot group before you then
administer to a larger
audience.
So there are a lot of steps in
survey development to try and ensure
that your results are ideally
(18:35):
as reproducible as possible,
recognizing that obviously
it's very hard to make
sure that if you administered the
survey, let's say a year later,
especially given that we administeredit
in the middle of the pandemic, that
you get similar responses, but
nonetheless to what extent to which
you can work with people who can
help you anticipate those type of
biases that are that prevent
(18:55):
reproducibility and wide
applicability that will make your
work better.
And I noticed that regarding
the incentives used to increase
survey response rate, you
offered entering into a drawing
for a $100 gift card.
Has this been shown to be effective
in high income survey participants?
(19:17):
Well, we're not in a position to
offer incentives to every single
person. We sent this out to
thousands and thousands of people.
But everyone thinks their
odds are better in a lottery than
they probably are.
So even $100 seems like,
heck, what's 10-15 minutes
so I can win $100 gift card?
So people seem to be incentivized by
this. Some incentive matters.
(19:38):
People hardly ever complete
something for nothing, but
having at least a little bit of a
carrot seem to induce people to want
to participate.
I think also people were pretty
happy to participate during the
pandemic. I have to say, I think we
were all home and a lot of us
actually upped our research
productivity remarkably during that
time.
When we weren't balancing home
school and
(19:59):
trying to stay safe and doing
emergency surgery.
But I think that
it was actually a time when people
were willing to help each other
because we are all in the same boat
trying to find a way forward during
a very strange time.
Are you planning to repeat the
survey now that things have
gotten a little bit closer to
normal?
Not at this time, one thing I am
(20:19):
looking forward to is
letters to the editor and responses
to our work.
As I mentioned, this is
the first or one of the first of
several publications that
will likely emerge from
the data, the rich data that we
collected from that survey.
And I think that that may
very well prompt our future work.
(20:41):
The first author for this
project, Yoshiko Iwai
is a
senior medical student at the
University of North Carolina, Chapel
Hill, and she is absolutely
outstanding.
She reached out to me in the middle
of the pandemic and
I didn't even meet her for almost a
year when I was on the faculty at
(21:02):
Duke. And we started working
together then, and we've
had just an incredibly productive
collaboration over the past three
years. And she'll be coming to a
general residency near you very
soon, and is just an absolute star.
So that's all just to say that she
was a huge force in
getting the survey off the ground
and getting it distributed.
(21:23):
And I hope to work
with her and figuring out where we
should take this work next.
That's great.
That's a wonderful story to hear
about how she was able to to
make the best use of that
that strange pandemic times and
parlay it into a Journal of the
American College of Surgeons
publication before even starting
residency.
(21:44):
Of the 183
professional organizations and 198
medical schools that you reached
out to, it looks like only
about 10% of them agreed
to participate.
So you have a very large sample size
to begin with, but it could have
been ten times larger.
Did you notice any gaps in
the representation?
(22:05):
Like what what specialties, if any,
are missing?
And are there any geographic regions
of the country that are
underrepresented in your dataset?
That's a great question.
We actually didn't suffer too much
geographically.
What I would say we potentially
have a slight underrepresentation
of are individuals who don't
(22:26):
belong to
an identity based organization.
We have to give a lot of credit
to the Association of Women
Surgeons,
to other groups
that have either
kind of gender or race, ethnicity
or other types of identity
based reasons for membership.
(22:48):
They those groups did a
phenomenal job at distributing
this to their membership.
We frankly did not have that from
our kind of more larger, generalized
professional societies.
Some of those groups don't even have
mailing email lists, if you can
believe it.
And if they have mailing lists, they
are paper mailing lists.
(23:09):
And those paper mailing lists
cost a lot of money for the
privilege of sending a survey to
its members, which of course, we all
know are unlikely to be returned
because it's paper mailing lists.
And so what I actually
would say is I think we have a
danger of underrepresentation of
retired individuals
who are obviously and so are
(23:29):
older individuals who may be a
little bit less likely to use email
and may also be a little bit less
likely to be part of an identity
based group.
I think we probably have
underrepresentation, almost
certainly of white men, frankly,
of white heterosexual men.
And so, you know, that gives
me pause because I think that
we need to
(23:51):
it was very surprising to me
how hard it was to
take the temperature of American
medicine while doing this survey.
And, of course, the other groups
that we would have to think about is
how do you contact the community
physician as you went through
medical schools, you went through
professional societies.
But if you are a community,
(24:12):
community physician doing important
work in an area
where you are not really active
in your local, you know,
professional society, you're not
really active in your national
society, you don't belong
to an identity based group who
is listening out for you and who's
finding out what matters to you,
who's serving as your voice.
(24:32):
And I don't think that's clear.
And that was a very interesting
thing to emerge as part of this
process of trying to collect
information.
Great. Thank you for that.
So another question I wanted to ask,
and I'm not sure if we'll find the
answer today, but it seems
like leadership in medicine
requires a different skill set
(24:53):
than what is typically taught in
undergraduate and graduate medical
education.
However, I think it is commonly
taught formally in like, for
example, business school curriculums
and other disciplines.
Should we be making room in the
medical education curriculum
for leadership training?
(25:13):
That's a great question.
You know, I think about the fact
that, frankly, as soon as you're,
you know, an intern, you're leading
someone, right?
You're leading the medical students
on your team, you're
helping them or they're helping you,
you know, get vitals and, you
know, change dressings like your
pre-rounding.
But even though we are in training
(25:33):
for a long time and don't become
attendings often till our
mid-thirties, especially within
surgery, the truth of the
matter is we are
functioning as middle management for
a very long time, while just
being paid like minions.
And so I think that
in terms of teaching leadership,
that would be an incredibly useful
thing because unfortunately I think
(25:55):
our pedagogical approach in
surgical education is too
observatory. It's too much, you
know, to see one do, one teach one,
and not enough emphasis on actual
skills that would improve our
pedagogical efficacy.
That being said,
you know, do you need to be talking
to people about how to be a division
chief when they're interns?
Probably not.
(26:16):
Or when they're medical students?
Probably not.
What is notable, though, is that the
things that we reward people
for in medicine
going beyond surgery, how we promote
people we promote people based
on their scholarship,
you know, Are you a independent
investigator?
Do you have funding from the
federal government?
(26:37):
What's your H index?
Do you already lead a team, however
means got you there.
And have you been
doing that for a long time?
And it's kind of striking to think
about. Are those really the criteria
that that translate into great
leaders?
(26:58):
And I think that maybe what we
need to really
think about is.
And also, I would say and also
you're a great surgeon.
And also I would say that maybe some
of the people who are
all of those things want to do
the next big thing in their career.
And the only path forward is to
become a division chief or a
department chair. They probably
(27:18):
would rather keep doing more of what
they're doing.
They just don't know what more of
what they're doing would look like
with a promotion kind of status.
So I think it might be worth
thinking about, one, whether
we're grooming our leaders
in the right way, whether we're
selecting leaders based on the right
criteria, and whether we can be more
(27:38):
creative and thinking about what
leadership or at least promotional
activities should look like for
individuals who have achieved
according to our traditional
metrics, but don't necessarily want
to be a department chair or
a cancer center director or center
of a transplant institute or
vascular institute or what have you.
You know, we're surgeons.
We can do hard things.
I think we should think a bit more
(28:00):
about how to have
better leaders, but also how to make
the people in our field as
they advance happier as they
advance.
Yeah I along that lines
I've heard that
in other industries, for example
like the tech industry they've
now created parallel tracks for
(28:20):
for career advancement that don't
involve going into management
and administration.
Like you can stay as a master
engineer or a master programmer
and still have that recognition
and status and earn
salary gains without having to
become, you know, division chief or
project manager, etc..
So maybe it's time to look at
(28:42):
that within medicine as well.
You've given us a lot of great ideas
about how to mitigate
imposter syndrome.
Do you have any final thoughts or
any other suggestions
on on what we can do to
help either treat
or prevent this
very prevalent problem?
(29:03):
You know, I think we just really
need to remember that
if the surgical field or
medicine doesn't look the way
American society looks,
that's not on the people who are
missing.
You know, it's on our profession
to bring more people into the fold.
And if whatever we're
doing to make medicine not
(29:24):
feel like a welcoming place
and to make surgery potentially even
less so, I think that requires
some introspection on our part.
I love surgery, and I have to say I
feel very blessed that I have felt
welcomed since the minute I
walked into an OR.
But I know that's not the case for
everyone.
But that being the case for me,
it changed my
(29:46):
life and it could change so many
people's if they had that similar
kind of seminal experience.
Well, it's been an absolute pleasure
speaking with Dr Fayanju today.
I encourage everyone to read this
excellent paper, which is available
now online ahead of print
and will be published in the October
2023 issue of the Journal of
the American College of Surgeons.
Thank you for listening to The
(30:07):
Operative Word.
Please send us any feedback at
postmaster@facs.org.
Thank you for listening to the
Journal of the American College of
Surgeons Operative Word Podcast.
If you've enjoyed today's episode,
spread the word on social media by
using the hashtag
#JACSOperativeWord.
(30:28):
Subscribe to The Operative Word
wherever podcasts are available
or listen on the American College of
Surgeons website at
FACS.org/Podcast.
Welcome to The Operative Word,
a podcast brought to you by the
Journal of the American College of
Surgeons.
I'm Dr. Jamie Coleman.
And throughout this series, Dr.
Dante Yeh and I will speak with
recently published authors about the
motivation behind their latest
research and the clinical
implications it has for the
practicing surgeon.
(00:22):
The opinions expressed in this
podcast are those of the
participants and not necessarily
that of the American College of
Surgeons.
Welcome to The Operative Word, a
podcast from the Journal of the
American College of Surgeons.
I'm Dr. Dante Yeh, one of your
co-hosts for this series.
In this episode, we'll be taking an
in-depth look into the current
article, Leadership and Imposter
(00:44):
Syndrome in Surgery.
I'm honored to be joined by the
senior author, Dr. Lola
Fayanju, MD, MA, MPHS, FACS, Chief
of Breast Surgery at the University
of Pennsylvania.
Dr. Fayanju, thank you for joining
me today. Before we begin, do
you have any potential conflicts of
interest to disclose?
(01:05):
I was funded by a
K08 award from the National Cancer
Institute during the time that the
study was being completed.
Great. Thank you.
And congratulations.
Why don't we start by having you
give us a brief summary of your
study and tell us about your main
findings.
So my study team and I conducted
a cross-sectional survey that was
(01:26):
administered to physicians across
the United States over approximately
six months in
2021. So really during the height of
the pandemic, and I really
had a fantastic team,
multi-disciplinary, consisting of
medical students as well as
internists, as well as surgeons.
And we were actually asking
a number of questions about
(01:47):
the types of factors that are
associated with who goes into
medicine, who holds leadership
positions in medicine, and people'strajectory
through medicine. And the question
about imposter syndrome specifically
was a subset of this larger
survey.
And in this survey, we
specifically asked individuals,
first of all, whether or not they
were in leadership.
And then we sought to find out
(02:09):
amongst those who were in leadership
and not in leadership, what
factors were associated with being
in leadership as well as what
factors were associated with their
experiencing imposter
syndrome.
And, imposter syndrome, as
many of you will have heard
is an internalized sense of
incompetence or not belonging.
It is something that's often been
ascribed to individuals from
(02:30):
minoritized backgrounds in
whatever situation in which they
find themselves the minority.
So it might be women in the field
of surgery as there are fewer women
in the field of surgery.
It might be people of color in the
field of surgery. Likewise, where
there are fewer people of color
and it might be people from the
LGBTQ community, for example, in
more heteronormative circumstances.
And so the idea is that imposter
(02:51):
syndrome is something that
individuals within these minoritized
groups or groups that are in some
other way marginalized feel,
and that does not reflect their
actual ability or skillset,
but nonetheless reveals
their feeling that they don't belong
to a larger whole and that they
don't feel frankly worthy
of being part of that whole.
And that might contribute to their
(03:12):
ability to be full participants
in that group and to achieve as
fully when they are ascribed
leadership roles or tasks
or other types of responsibility
as part of that group membership.
And in the end, we
had approximately over
2000 people, a combination
of retired and attending physicians,
(03:32):
mainly attending physicians,
who responded to this portion of
our our survey.
And what we found is that
overall women were more likely
to experience imposter syndrome than
men quite significantly.
But we did not find this association
when we looked at people from
racially and ethnically minoritized
backgrounds, and we did
(03:53):
not find that this differed even
when they were women,
for example. So the intersection
of being a racial ethnic minority
and being a woman and we didn't find
this, whether or not people were in
leadership roles or not.
And so our conclusion was that it's
interesting to find that female
physicians are more likely to
experience imposter syndrome than
men, regardless of specialty.
(04:13):
As I said, we went across a number
of different specialties and had
also a multidisciplinary research
team and also regardless
of leadership status, but that when
we looked at racially and
ethnically defined identities, we
did not see an association
or a higher prevalence of imposter
syndrome in minoritized
groups.
And the reason this is fairly
(04:34):
important is because people have
often used imposter syndrome
as a reason for why there might
be a lower
or rather a slower climb and
participation of minoritized
individuals in majority
groups. So the reason there might be
a slower gain amongst black men,
for example, in having proportional
representation amongst physicians
(04:56):
or slower gain in whatever other
type of group, that that might be
because of internalized imposter
syndrome. What our findings suggest
is that actually we need to look
elsewhere. This is not about some,
frankly, you know,
internalized sense of incompetence
or not belonging.
We have to look for other reasons
for why certain groups are still not
represented at the rates they should
be in our field of
(05:18):
medicine and within surgery as well.
Great. Well, thank you for that
brief summary.
There's a lot to unpack here,
and I was taking down some notes.
So it sounds to me that
your study concludes that
female physicians were more likely
than male physicians to experience
the imposter syndrome or
(05:39):
to report that they had the feelings
of imposter syndrome on this survey,
regardless of specialty
or leadership role.
However, when you looked at racial
background, that that was not the
case. Am I summarizing it correctly?
Correct.
Do you know, is this
phenomenon being shown
(05:59):
in other fields or is it unique
to just medicine?
So unfortunately, we have seen
that there is imposter syndrome
seen frequently
in other fields outside of medicine
among women.
And we do typically see this also
with regards to racial and ethnic
minorities, which is why our
findings specifically
(06:21):
where there is divergence between
those who are part of were
female versus those who were
racially and ethnically minoritized
physicians.
We were surprised to see that split.
While typically we've seen that
that is observed more in both
of those groups and other fields,
such as business or
other types of non-healthcare
fields.
(06:42):
And again, it's interesting,
it makes us just have to question
again more whether
we are looking at the right types of
things.
You know, a lot of people have
concerns about the term imposter
syndrome for a number of reasons.
One, it
ascribes the lack of belonging or
the lack of membership or
participation by a particular
(07:04):
group or particular individuals from
groups as seeming like
the fault of those individuals
versus the fault of the majority
group to which they are being, from
which they're being excluded.
And so, you know, imposter syndrome
has in some level is questioned
as a as a real entity that maybe
it's something that's actually being
imposed on people that's
internalization of an unfair
assessment by others versus
(07:25):
something that results from any type
of lack or self-perceived
lack by the individuals who are
reported as having it.
And so I think it's important
that even though we you know, we
asked about this and we saw this
interesting finding, it just makes
us, again, question the extent to
which we have non-diverse
specialties, non diverse fields.
How much are we ascribing the blame
(07:46):
for that, either implicitly or
explicitly to the individuals who
are being excluded versus they're
not participating?
How much are we really taking on the
burden of our of our field
versus blaming individuals for not
feeling like members of a field
that's been very homogeneous for a
very long time?
Yeah, that that's that raises a lot
of questions, which I think at this
(08:08):
generic or general very
broad view from the survey that you
have, it's going to be impossible to
to answer those questions until we
drill down at a more granular
level.
You mentioned earlier that one
potential way that
this can manifest is that if an
individual has the sense
of imposter syndrome, they may be
(08:30):
less likely to participate
and that may
hold them back or that may adversely
affect their promotions and
their career track.
Are there any other like mechanisms
of action that that have been
tested or or proven,
for example, in other fields that
that could connect the dots from
this individual has the sense
(08:51):
of imposter syndrome to
this individual is now
underrepresented
in leadership positions.
So there has been some evidence
that because impostor syndrome
is frequently associated with
anxiety and burnout, and I want to
emphasize associated with so
we can't be sure whether impostor
syndrome is the kind of thing that
(09:11):
results in people who already have a
predisposition for anxiety
or susceptibility to moral
injury that can be experienced by
people in health care, or
whether or not imposter syndrome
leads people to having those
experiences. So I just want to
emphasize that.
But nonetheless, since we know that
there is an association between
imposter syndrome and anxiety and
(09:31):
burnout, we have seen that
interventions that target,
you know, any of those things can
have an effect on the other.
So, for example, there's been
evidence that coaching, professional
coaching can actually have a
significant effect on improving
imposter syndrome, but
can also frankly improve the
likelihood of someone developing
other skill sets that lead to
(09:52):
professional advancement.
Right. So it's a little bit tricky
because imposter syndrome is in
itself something
that has a definition, but that
may manifest itself differently in
individuals, even within
different fields that
and then the interventions that are
used for imposter syndrome
may also have
an impact on
(10:14):
other characteristics also
associated with imposter syndrome.
So it's hard to isolate, you know,
what the cause and effect is
as regards to the intervention.
But nonetheless, it seems that
coaching as well as
interventions that specifically
target wellness, which is supposed
to, all of these are supposed to
help peer mentorship is
actually supposed to be very
(10:34):
important in terms
of potentially helping individuals
see that they are not different.
And then thinking beyond the
individual work and thinking more
about systemic interventions,
really
making it clear from an
institutional level
that someone belongs by the simple
(10:54):
act of making sure they're being
paid at the same level as
their majority peers, and
that they know that.
I think one of the things a lot of
women in particular experience is
this concern
that they might be being paid less
than their male peers, only to often
have that verified when they
actually directly ask people.
(11:14):
But when there's public
knowledge of salaries, which is
something that a lot of public
institutions have to do,
but that also some private
institutions choose to do
as part of moves towards equity
and avoiding kind of pay
discrepancies by gender and by race
ethnicity, that that
is thought to be potentially a way
which to assure people we really
(11:36):
do value as much as your, you know,
your your majority peers that
we are showing you that in dollars
and cents, not just in words.
And so I think that that is one way
we can do that.
One way I would also imagine is
that we know that the way in which
we value people, not just dollars
and cents, but also in terms of the
kinds of things we ask people to do.
(11:57):
We know that, you know,
women in particular, but
also people of color often do a lot
of the housekeeping work of
departments in the housekeeping work
of divisions, the kind of
lubricating tasks that make
divisions and departments run work
and feel like good places to be, but
then often are rewarded with or
translate into promotion.
(12:18):
And so if we disproportionately
give those individuals
the types of
jobs and assignments,
like, you know, Vice chief of
wellness or vice chief
of
party planning, I'm not really
saying that, you know, the kinds of
positions that we know, again,
do make everyone enjoy being
(12:39):
at work much more, but are not going
to make their way to the COAP
committee, that is the committee for
advancing and promotion, then
that doesn't show that you really
believe those people belong there in
the same way that the vice chair of
research might belong there, or the
vice chair or the Chief of
Vascular Surgery belongs there,
doesn't show that you really value
them the way that you value people
(13:00):
who are more likely majority and
more likely to hold the types of
roles that are objectively seen as
vital and important for the
department.
That's an excellent point, which I
had not even considered.
So. So thank you for that.
Your your study focused on
individuals who are holding
leadership positions in medicine.
(13:21):
Do you think that the
prevalence of imposter syndrome
is equally
widespread in in
physicians who are not in leadership
positions?
Oh, I mean, there's evidence to
believe that it's more so that, you
know, to become a leader means that
you you either didn't have
imposter syndrome or managed to
(13:41):
suppress it quite effectively
in order to achieve the status one
now holds. And so
I think what's notable is that when
you see this difference in
women, these are women
who have imposter syndrome and made
it anyway. So, you
know, they shattered the glass
ceiling while carrying this very
heavy burden.
And so I think that that says a
(14:03):
lot again about the fortitude
and the resilience of individuals
who even while feeling that they
might be less than persevered
nevertheless.
And what I think is important is to
realize that if we don't see
imposter syndrome
in the racially minoritized
individuals who we saw amongst
leadership here, it may be because
(14:23):
you have to be someone who
already really has
a deep sense of belonging
to even aspire to and achieve
leadership. If you are from a
racially minoritized background, you
know this survey was part of,
as I mentioned, a larger survey.
We also ask questions about the
likelihood of your whether or not
you had a family member in medicine.
(14:44):
And I think about that all the
time. I think it's really striking
when you look around your med school
class and realize how many people
have parents in medicine, sometimes
grandparents in medicine, and how
much more that will affect your
ability to feel like you belong
there than if you're first
generation.
And so that is to say that I think
even amongst the women and
(15:04):
the racial, ethnic minority
individuals who are in medicine,
there is some belief and that's
something that will hopefully emerge
when we when we actually share this
data from the larger survey with
the world, that it
does matter that you have
external and internal
sources of resilience that confirm
for you that you belong there, even
(15:26):
if you have other messages coming
at you that suggest that you do not.
And so that is to say that it might
be that the types of racial and
ethnic minorities who are becoming
leaders are imbued and
buoyed by other types
of resources that are not
perceptible and that are unmeasured,
but nonetheless sustain them and
(15:46):
prevent imposter syndrome from
rearing its ugly head, even when
you might expect it would.
So it sounds like we have a little
bit of a selection bias in
this particular study and
we may be under, well, we're
definitely underestimating
the prevalence of imposter syndrome
in medicine.
I strongly suspect so.
You know, I think, you know, even
(16:09):
having the ability to respond to a
survey, as we know, people who are
miserable don't respond to surveys,
people who feel like they're not
succeeding, don't respond to
surveys. So even though this was
admit, you know, this was sent to
thousands and thousands of
physicians across the country,
hardly anyone is going to respond if
they feel like they're really
struggling.
And that's one of the challenges of
conducting survey research, of
course.
(16:29):
But nonetheless, I think the fact
that we saw a signal says a lot.
Yeah, and that's a great segue.
I had a couple of questions about
the actual execution
of the survey.
I noticed that in
the methods that you sought
professional guidance
from a survey expert,
which I haven't
(16:50):
seen very commonly, but
after reading this study,
I thought it was great.
Can you can you talk to us a little
bit more about what did this survey
expert recommend and how did you
refine your methods based on their
input?
So I have a masters
in Population Health Sciences and
I have done qualitative work
(17:11):
and received qualitative training.
But.
I don't have a doctorate in
ethnography or I don't
regularly do, you know, grounded
theory as part of my routine work.
I don't conduct surveys or perform
psychometric work in my everyday
life. And so I
have the humility to realize that
I need to
(17:32):
often make sure that we're doing
this kind of thing correctly so.
So when I offer this advice
to others who might be interested in
conducting or creating a survey,
typically you want to work with
someone who or people who have that
kind of expertise.
We work with the Odum Institute at
the University of North Carolina,
which is a nationally,
if not world renowned site
(17:53):
for qualitative
research, education
and implementation.
And worked with them to review our
survey to make sure that
as we were setting up our questions,
we weren't necessarily priming
people's responses based on the
order in which the questions were
placed and the language
with which they were written.
(18:14):
In addition, you typically want to
do kind
of a test group first where you make
sure that the questions make sense
and they're kind of not
misinterpreted within the initial
pilot group before you then
administer to a larger
audience.
So there are a lot of steps in
survey development to try and ensure
that your results are ideally
(18:35):
as reproducible as possible,
recognizing that obviously
it's very hard to make
sure that if you administered the
survey, let's say a year later,
especially given that we administeredit
in the middle of the pandemic, that
you get similar responses, but
nonetheless to what extent to which
you can work with people who can
help you anticipate those type of
biases that are that prevent
(18:55):
reproducibility and wide
applicability that will make your
work better.
And I noticed that regarding
the incentives used to increase
survey response rate, you
offered entering into a drawing
for a $100 gift card.
Has this been shown to be effective
in high income survey participants?
(19:17):
Well, we're not in a position to
offer incentives to every single
person. We sent this out to
thousands and thousands of people.
But everyone thinks their
odds are better in a lottery than
they probably are.
So even $100 seems like,
heck, what's 10-15 minutes
so I can win $100 gift card?
So people seem to be incentivized by
this. Some incentive matters.
(19:38):
People hardly ever complete
something for nothing, but
having at least a little bit of a
carrot seem to induce people to want
to participate.
I think also people were pretty
happy to participate during the
pandemic. I have to say, I think we
were all home and a lot of us
actually upped our research
productivity remarkably during that
time.
When we weren't balancing home
school and
(19:59):
trying to stay safe and doing
emergency surgery.
But I think that
it was actually a time when people
were willing to help each other
because we are all in the same boat
trying to find a way forward during
a very strange time.
Are you planning to repeat the
survey now that things have
gotten a little bit closer to
normal?
Not at this time, one thing I am
(20:19):
looking forward to is
letters to the editor and responses
to our work.
As I mentioned, this is
the first or one of the first of
several publications that
will likely emerge from
the data, the rich data that we
collected from that survey.
And I think that that may
very well prompt our future work.
(20:41):
The first author for this
project, Yoshiko Iwai
is a
senior medical student at the
University of North Carolina, Chapel
Hill, and she is absolutely
outstanding.
She reached out to me in the middle
of the pandemic and
I didn't even meet her for almost a
year when I was on the faculty at
(21:02):
Duke. And we started working
together then, and we've
had just an incredibly productive
collaboration over the past three
years. And she'll be coming to a
general residency near you very
soon, and is just an absolute star.
So that's all just to say that she
was a huge force in
getting the survey off the ground
and getting it distributed.
(21:23):
And I hope to work
with her and figuring out where we
should take this work next.
That's great.
That's a wonderful story to hear
about how she was able to to
make the best use of that
that strange pandemic times and
parlay it into a Journal of the
American College of Surgeons
publication before even starting
residency.
(21:44):
Of the 183
professional organizations and 198
medical schools that you reached
out to, it looks like only
about 10% of them agreed
to participate.
So you have a very large sample size
to begin with, but it could have
been ten times larger.
Did you notice any gaps in
the representation?
(22:05):
Like what what specialties, if any,
are missing?
And are there any geographic regions
of the country that are
underrepresented in your dataset?
That's a great question.
We actually didn't suffer too much
geographically.
What I would say we potentially
have a slight underrepresentation
of are individuals who don't
(22:26):
belong to
an identity based organization.
We have to give a lot of credit
to the Association of Women
Surgeons,
to other groups
that have either
kind of gender or race, ethnicity
or other types of identity
based reasons for membership.
(22:48):
They those groups did a
phenomenal job at distributing
this to their membership.
We frankly did not have that from
our kind of more larger, generalized
professional societies.
Some of those groups don't even have
mailing email lists, if you can
believe it.
And if they have mailing lists, they
are paper mailing lists.
(23:09):
And those paper mailing lists
cost a lot of money for the
privilege of sending a survey to
its members, which of course, we all
know are unlikely to be returned
because it's paper mailing lists.
And so what I actually
would say is I think we have a
danger of underrepresentation of
retired individuals
who are obviously and so are
(23:29):
older individuals who may be a
little bit less likely to use email
and may also be a little bit less
likely to be part of an identity
based group.
I think we probably have
underrepresentation, almost
certainly of white men, frankly,
of white heterosexual men.
And so, you know, that gives
me pause because I think that
we need to
(23:51):
it was very surprising to me
how hard it was to
take the temperature of American
medicine while doing this survey.
And, of course, the other groups
that we would have to think about is
how do you contact the community
physician as you went through
medical schools, you went through
professional societies.
But if you are a community,
(24:12):
community physician doing important
work in an area
where you are not really active
in your local, you know,
professional society, you're not
really active in your national
society, you don't belong
to an identity based group who
is listening out for you and who's
finding out what matters to you,
who's serving as your voice.
(24:32):
And I don't think that's clear.
And that was a very interesting
thing to emerge as part of this
process of trying to collect
information.
Great. Thank you for that.
So another question I wanted to ask,
and I'm not sure if we'll find the
answer today, but it seems
like leadership in medicine
requires a different skill set
(24:53):
than what is typically taught in
undergraduate and graduate medical
education.
However, I think it is commonly
taught formally in like, for
example, business school curriculums
and other disciplines.
Should we be making room in the
medical education curriculum
for leadership training?
(25:13):
That's a great question.
You know, I think about the fact
that, frankly, as soon as you're,
you know, an intern, you're leading
someone, right?
You're leading the medical students
on your team, you're
helping them or they're helping you,
you know, get vitals and, you
know, change dressings like your
pre-rounding.
But even though we are in training
(25:33):
for a long time and don't become
attendings often till our
mid-thirties, especially within
surgery, the truth of the
matter is we are
functioning as middle management for
a very long time, while just
being paid like minions.
And so I think that
in terms of teaching leadership,
that would be an incredibly useful
thing because unfortunately I think
(25:55):
our pedagogical approach in
surgical education is too
observatory. It's too much, you
know, to see one do, one teach one,
and not enough emphasis on actual
skills that would improve our
pedagogical efficacy.
That being said,
you know, do you need to be talking
to people about how to be a division
chief when they're interns?
Probably not.
(26:16):
Or when they're medical students?
Probably not.
What is notable, though, is that the
things that we reward people
for in medicine
going beyond surgery, how we promote
people we promote people based
on their scholarship,
you know, Are you a independent
investigator?
Do you have funding from the
federal government?
(26:37):
What's your H index?
Do you already lead a team, however
means got you there.
And have you been
doing that for a long time?
And it's kind of striking to think
about. Are those really the criteria
that that translate into great
leaders?
(26:58):
And I think that maybe what we
need to really
think about is.
And also, I would say and also
you're a great surgeon.
And also I would say that maybe some
of the people who are
all of those things want to do
the next big thing in their career.
And the only path forward is to
become a division chief or a
department chair. They probably
(27:18):
would rather keep doing more of what
they're doing.
They just don't know what more of
what they're doing would look like
with a promotion kind of status.
So I think it might be worth
thinking about, one, whether
we're grooming our leaders
in the right way, whether we're
selecting leaders based on the right
criteria, and whether we can be more
(27:38):
creative and thinking about what
leadership or at least promotional
activities should look like for
individuals who have achieved
according to our traditional
metrics, but don't necessarily want
to be a department chair or
a cancer center director or center
of a transplant institute or
vascular institute or what have you.
You know, we're surgeons.
We can do hard things.
I think we should think a bit more
(28:00):
about how to have
better leaders, but also how to make
the people in our field as
they advance happier as they
advance.
Yeah I along that lines
I've heard that
in other industries, for example
like the tech industry they've
now created parallel tracks for
(28:20):
for career advancement that don't
involve going into management
and administration.
Like you can stay as a master
engineer or a master programmer
and still have that recognition
and status and earn
salary gains without having to
become, you know, division chief or
project manager, etc..
So maybe it's time to look at
(28:42):
that within medicine as well.
You've given us a lot of great ideas
about how to mitigate
imposter syndrome.
Do you have any final thoughts or
any other suggestions
on on what we can do to
help either treat
or prevent this
very prevalent problem?
(29:03):
You know, I think we just really
need to remember that
if the surgical field or
medicine doesn't look the way
American society looks,
that's not on the people who are
missing.
You know, it's on our profession
to bring more people into the fold.
And if whatever we're
doing to make medicine not
(29:24):
feel like a welcoming place
and to make surgery potentially even
less so, I think that requires
some introspection on our part.
I love surgery, and I have to say I
feel very blessed that I have felt
welcomed since the minute I
walked into an OR.
But I know that's not the case for
everyone.
But that being the case for me,
it changed my
(29:46):
life and it could change so many
people's if they had that similar
kind of seminal experience.
Well, it's been an absolute pleasure
speaking with Dr Fayanju today.
I encourage everyone to read this
excellent paper, which is available
now online ahead of print
and will be published in the October
2023 issue of the Journal of
the American College of Surgeons.
Thank you for listening to The
(30:07):
Operative Word.
Please send us any feedback at
postmaster@facs.org.
Thank you for listening to the
Journal of the American College of
Surgeons Operative Word Podcast.
If you've enjoyed today's episode,
spread the word on social media by
using the hashtag
#JACSOperativeWord.
(30:28):
Subscribe to The Operative Word
wherever podcasts are available
or listen on the American College of
Surgeons website at
FACS.org/Podcast.
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