The first week of my big attending job, I saw a patient with fever, sore throat, no cough, and tonsillar exudates. Well-trained to manage septic shock, but having no idea how to practice in a primary care clinic, I crafted a vast array of infectious and inflammatory diagnoses. With a quick glance, my senior partner said, “You don’t know that this is strep?”

Flushed and wanting to hide, I thought, “I am such an idiot. I’m totally going to kill all my patients. This is a disaster.”

As predicted, the July 1 transition at every stage of medical training and practice is the signal for our inner impostor to arrive. I don’t care for the term “impostor syndrome” because it pathologizes the normal human emotion of uncertainty. It is important to clarify some terminology:

• Uncertainty: lack of sureness about someone or something. Totally normal, helpful emotion. For example, when a patient presents with a diagnosis that you don’t quite believe, uncertainty helps you recognize that you need to dig deeper for accuracy. Uncertainty in small doses keeps us curious.
• Impostorism: uncertainty + shame. Picture being a new intern or new attending seeing a clinical presentation you don’t recognize, and telling yourself, “I have no idea what this is. I should know this. What is wrong with me? Everyone is going to know I have no idea what I’m doing.” Impostorism creates an erroneous story about our uncertainty. It tells us that we are not worthy, everyone will find out, and we will die of humiliation.
• Systems of oppression: every person/institution of power that convinces you that you are not worthy and contributes to the impostor narrative. For example, “Women don’t belong in surgery,” “Natural hair is not professional,” and “These new docs just complain. They don’t work hard enough.” These forces, through bias and exclusion, provide a narrative that we internalize (and believe) that we are unworthy and unqualified; therefore, we should not try or conform, and consequently, systems of power are not disrupted.

So, what are you telling yourself about uncertainty in this new PGY stage?

What is the narrative that you hear when faced with uncertainty?

Whose voice is telling you that?

Is that story true or is it an erroneous narrative that you internalized over time?

Ultimately, our critical impostors are simply trying to keep us safe from vulnerability, failure, and exposure. If they can just get loud, we will get small and quiet and safe, thereby limiting our potential, our impact, and our power.

We can anticipate impostorism. Predictably, impostorism shows up at times of uncertainty and new responsibilities — career transition points, new leadership roles, new social environments. Of course, when you transition on July 1 and gain new responsibilities, your inner impostor will be waiting to greet you. When you look at your shiny new ID badge and feel nervous about what lies ahead, and then your critic gets mouthy, you can think, “Oh, I knew you would be here.”

Please know that there is no threshold of success that will ever eliminate impostorism. Michelle Obama famously described how her impostor syndrome followed her to the most powerful rooms in the world. This year, as a PGY-18, I found myself thinking, “These new docs know so much more than I do. I’m totally out of date.” What? Thanks, Impostor. Not true. Not helpful.

What can you do to silence your impostor?

1. Get a hype girl/hype man. (See how that patronizing terminology contributes to impostorism? No one calls men hype boys.) Fine, get a hype-team. Who are your cheerleaders who will celebrate your strengths and accomplishments? Ask them, “What am I great at? What am I known for? What is my superpower?” Know your strengths and own them. You are not great at everything, and that’s normal. Your impostor wants to reframe “your areas for growth” as “proof of unworthiness.” Don’t believe that hype.
2. Keep a victory list — an email folder or a list in your reminders work well. Write down your victories, big and small, and come back to them when you need proof of your accomplishments. I keep a drawer with letters from patients as a reminder that the work I do matters.
3. Know that your inner impostor is doing their job — to keep you safe. With compassion, remind yourself, “Thanks, brain. I know this is scary. I’m learning to profoundly have my own back, and I’m going to do this anyway.”
4. Attendings, model healthy uncertainty for your teams. Tell them when you don’t know the answer. Tell them it’s normal to feel exposed when they are new PGY-whatevers. Tell them that uncertainty is a superpower that helps them recognize when a diagnosis doesn’t seem right.

You can never avoid the totally normal feeling of uncertainty. You can, however, decide what you make it mean. Let uncertainty lead you toward the zebra you never thought you’d see. Then add that to your victory list.

Kara Pepper, MD, is an internal medicine physician and can be reached at her self-titled site, Physician Coach: Kara Pepper, MD.

This post appeared on KevinMD.

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