Recognizing the Impact of Impostor Phenomenon and Microaggressions in Gastroenterology

The percentage of women in medical school has essentially doubled over the past 50 years, and women represent 50% of medical students today.1 The percentage of medical school students who identify as racial/ethnic underrepresented minorities (URMs) has also increased. As of 2022, non-white URMs represented 50.6% of enrolled medical students.2 However, despite these advancements, just 25% of practicing gastroenterologists are female, and 9% of gastroenterologists identify as URMs.

A newly published study in the journal Gastroenterology demonstrates the majority of women in gastroenterology (GI) surveyed about these to two issues report experiencing — impostor phenomenon (IP) and microaggressions (MA).

“Impostor phenomenon is a personal experience where the individual feels that despite their achievements and abilities they still perceive self-doubt about their earned abilities and success,” explains Carol A. Burke, MD, Staff gastroenterologist, Department of Gastroenterology, Hepatology and Nutrition, Director of the Hereditary Polyposis section at Cleveland Clinic and senior author of the paper. Individuals with IP dismiss their accomplishments as being a result of luck rather than skill and competency. However, while IP is an internal phenomenon, MAs are external assaults consisting of verbal, behavioral and environmental actions that are perceived by the recipient as hostile or derogatory. They’re usually a result of implicit bias, often slight and subtle – hence the name — and don’t involve any type of physical confrontation, but still have a substantial effect on work culture and a person’s feeling of self-worth.” She continues, “The combination of IP and MA can create a vicious, self-perpetuating cycle and cause real harm to the individual’s self-worth and the workplace whereby the environment doesn’t make them feel welcome and decreases diversity in the workforce.”

Research methods

To better understand the impact and frequency of IP and MAs, Dr. Burke, primary author Natalie Farha, MD, second-year GI fellow in the Department of Gastroenterology at the Cleveland Clinic surveyed attendees of a leadership conference for female health care professionals in GI. The survey was used to understand the prevalence of IP and MA and the need for enhanced awareness and educational programming on these topics to mitigate these experiences.

Following a lecture about IP and MAs, attendees were invited to voluntarily complete an anonymous survey that ascertained sociodemographic information (age, gender, employment status and years practicing as a gastroenterologist). Respondents were also asked two self-reflection questions: “Have you had feelings of impostor phenomenon?” and “Have you been a target of microaggression?”. The survey also included the Clance IP Scale (CIPS) — a 20-item questionnaire that helps determine the presence and severity of IP (the higher a score on a scale of 20 to 100, the more IP interferes with a person’s life).

Results

Of the 132 attendees, 86 (65%) completed the survey, and of those, 97.7% were female. A total of 17.4% of respondents were younger than 30 years, 50% were between 31 and 40, 25.6% were between 41 to 50 and 7% were older than 50 years. Nearly 50% of respondents were white, followed by 38.4% Asian, 5.8% Hispanic, and 2.3% Black. Fifty percent of respondents were practicing gastroenterologists, 21.3% were GI fellows, 13.8% were medical residents, 6.3% were advanced practice providers and 1.3% were medical students.

Respondents overwhelmingly responded affirmatively (88.2%) to the first question, “Have you had feelings of imposter phenomenon?”. Only 4.7% of respondents responded no, and 7.1% responded that they did not know. Nearly 93% stated affirmatively to the question: “Have you been a target of microaggressions?”. Less than 2% of respondents responded no (1.2%), and 6.1% responded that they did not know. The mean CIPS score of respondents was 66.8 (range, 39–91). Fifty-six of 86 (65.1%) respondents had IP, as defined by a mean CIPS score of 62 or higher (61 to 80 is considered frequent IP). Only 1.2% of respondents reported few IP experiences while 69% scored frequent to intense feelings of IP (score of 80 or higher). Black, younger, and trainee respondents had the highest IP scores compared with practicing gastroenterologists, advanced practice providers and other respondents. The authors note that CIPS scores also decreased with age.

Takeaways

“Unfortunately, these results weren’t very surprising,” explains Drs. Burke and Farha. “The environment within the medical profession is high-pressure, and it requires professionalism and respect between colleagues which is incumbent upon understanding systemic racism, sexism, classism and other biases.”

Dr. Burke notes that IP and MA lead to burnout, which affects over 50% of gastroenterologists and has a substantial association with mental health as well.

“A few previous studies assessed the relationship between IP, MA and burnout,” says Dr. Burke. “Both IP and MA affect burnout and disproportionally is prevalent in females and under-represented minority physicians particularly those who experience sexist or racial/ethnic MA.”

Overcoming IP and reducing MAs

As a result of their research, the authors outlined four strategies that can help mitigate the effects of IP. They include:

1. Increasing Awareness.
2. Celebrate Success.
3. Reframe Failure.
4. Pursue Professional Help.

By increasing awareness of IP, sharing experiences and seeking support, clinicians can become more aware of its prevalence. Celebrating success can also help clinicians recognize their value and boost their confidence and feeling of self-worth.

“Unfortunately, women in medicine, similar to those in other professional fields, are often ostracized for being direct and displaying confidence in the workplace,” says Dr. Burke. “Women are aware of this double standard, and they may feel uncomfortable sharing personal successes. However, overcoming IP requires building self-confidence, and celebrating accomplishments is one way to remind women of their strengths and abilities.”

Reframing failure as an opportunity and stepping stone to become better and more skilled physicians is important for personal growth. Failure is a universal experience and it shouldn’t be viewed as a sign of incompetence. Lastly, taking advantage of professional help can not only reduce IP among physicians, but it can also help reduce burnout.

Similar to their outline of strategies to overcome IP, the authors also provide four strategies to overcome MAs:

1. Educate. Organizations should increase awareness of MAs and provide training to overcome it.
2. Recognize Implicit Biases. Self-reflection can help identify personal implicit biases that may unintentionally contribute to MAs.
3. Foster Psychological Safety. Creating safe spaces for open and candid conversations can be implemented more easily when leaders model inclusive behaviors and language.
4. Revise Organizational Policies. leaders should ensure that organizational policies promote inclusivity and address potential sources of MAs. Employees should understand workplace policies and the repercussions if those policies are violated.

“Because MAs threaten a fully engaged and diverse workforce they can only be resolved when everyone is on board,” explains Dr. Burke. “The Digestive Disease Institute at the Cleveland Clinic has mandated MA training for all physician and nursing staff. We aim to be the best place to work and ensure we celebrate diversity and inclusion of all team members to mitigate employee turnover and foster professional success.

References

1. Current trends in medical education—AAMC diversity facts and figures 2016. Association of American Medical Colleges (AAMC). Accessed October 11, 2022. https://www.aamcdiversityfactsandfigures2016.org/report-section/section-3/#.
2. 2022 Fall applicant, matriculant, and enrollment data tables – AAMC. Association of American Medical Colleges. October 31, 2022. Accessed January 30, 2024. https://www.aamc.org/media/64176/download?attachment.