I was at a conference recently where the presenter confidently said, “There is no such thing as impostor syndrome! Because you are not an impostor! You deserve what you have achieved, you have earned it. So stop feeling like you didn’t.” If only it was as simple as she made it sound.
Impostor syndrome is a very common phenomenon, especially for people who have advanced their careers (for example, an RN who goes back to school to become an APRN). Though it’s prevalent in health care (in all disciplines and at all levels), it’s something that is also present across all demographics and industries. Anyone can be affected, but you may not even know, because it’s so isolating. When you are living with the unshakeable (and maybe even unrecognized) belief that you are a fraud and that it’s just a matter of time until you are found out and lose everything, you are not likely to shout it from the rooftops. But I will share when the thought surfaced for me, because it’s important we talk about it.
It was a day like any other in my first year of practice. I had a no show, another way of saying a moment to come up for air. With a few free minutes on my hands, I opened my inbox and picked out a couple of quick tasks to check off the list: normal lab results, update on a referral I had placed. And then a refill request for a controlled substance — no problem, this was a longstanding medication for this patient and within the appropriate refill window. As I clicked on the series of buttons that my EHR required in order to approve this medication, I thought to myself, “Can you believe they are letting me do this?”
A fairly natural thought, but also, what? Where did that come from? Why shouldn’t I be the one signing off on this medication? I had proven myself time and again: to my professors and preceptors, on my board exams, to my state licensing body, to the DEA, to my employer. They all thought that I had what it took. So why did this thought even cross my mind? I sensed a bit of impostor syndrome, and embraced it. I had a list of reasons that validated my ability to do precisely what I was doing, I could readily explain why I was doing it to anyone who might ask, and I knew that what I was doing was well within established and validated guidelines. But oh how easy it was for that sneaky little thought to pop up.
And I imagined I could see those thoughts above others’ heads. When I was in school, one of my preceptors (an NP) shared an office with two physicians. This preceptor was knowledgeable and seasoned, a great resource for both me as a student and her patients. But she would often discourage questions from me when either of the physicians was in the office, preferring me to defer those questions until we were alone. Her confidence in her answers and advice was noticeably stronger when we worked one on one; when the physicians were present, her tone of voice softened, her answers became more rote and circumspect. It was almost as if she was taking an oral exam and she did not want to fail. I chalked this up as a lesson learned: Would I dim my light in the presence of others, or would I work to maintain my clinical confidence?
The isolation of impostor syndrome can lead to some other nasty things, like perfectionism and burnout. Perfectionism has some benefits, but it’s not as good as it might sound, and very unrealistic — unachievable, really. Nursing school and graduate school challenge us to take in and retain a lot of critical information in a short period of time, and generally require maintenance of a certain GPA to remain enrolled. That can be enough to drive anyone to the point of aiming for perfection in the hope that you could even possibly get every “select all that apply” question correct.
The same things that make us want to get every question on the test correct can be the same things that lead us into unsustainable work habits that create ideal conditions for burnout. Of course, burnout is not that simple nor that black and white, and can be heavily influenced by factors beyond our control. If given the chance, burnout can unravel all of the hard work that went into crossing the finish lines of school and boards, all of the hard work that you do with your patients to provide them the best care. When you are burnt out, none of that matters, and a solution can be hard to imagine, leading many to throw in the towel altogether.
The AANP tells us that more than 70% of NPs work in primary care — a challenging clinical setting with a lot to manage even under the best of circumstances. Add to that the increasing demands as the largest segment of our population ages, the wave of clinicians beginning to retire from practice, and the loss of staff at all levels due to burnout, and it’s no wonder that a clinician in a primary care setting isn’t going to want to talk about how they feel like this was all some sort of major fluke and they really shouldn’t be here. They’re going to put their head down and do everything they can to NOT draw attention.
When you have this secret belief that you might be a fraud, you are going to work double time to make everything exactly right as much as you possibly can. You might let your patients get more of your energy than you are realistically able to give: running late in visits, answering patient messages after hours, rarely saying no even at your own expense. You want the best for your patients, which is admirable and should be the goal, but that doesn’t mean you have to be the person to do everything. The best for your patients can also mean effective delegating and it can also be setting and maintaining appropriate boundaries.
But the perfectionist in us, it lies to us. It makes us think that if we dot every I just so, if we cross every T precisely, then everything will be OK. Maybe you’ve tried this already, so you realize that it doesn’t work. You realize that all this does is exhaust you. Maybe you even thought the exhaustion is sort of OK, because if you are really tired, then you don’t have the energy to keep feeling so anxious — but really, would you recommend that strategy to a patient or a loved one? Why would you let it continue for yourself?
Maybe because we don’t know what else to do. I spend a lot of time thinking about the role change that we go through as we become NPs, and where we could be better prepared. Are impostor syndrome and perfectionism unavoidable? If we don’t have skills to recognize them before they become problematic, then yes. But what if we were taught to recognize the signs in ourselves (the self doubt, the blurred boundaries, the negative thoughts and fear)? What if we were taught how to address these very common feelings? Could that prevent burnout? Could that make the transition from RN to NP a little smoother? Is making that transition smoother better for us, or our patients — or both?
I cringed when I heard that conference speaker talk about how there is no such thing as impostor syndrome. I know she meant well, but impostor syndrome is very real, and it has a big impact in a clinical setting. If the clinician is struggling, how can we expect them to give the best care to their patients? How can we expect them to avoid burnout? How can we expect them to do the more, more, more that is constantly asked of them?
A simple solution for impostor syndrome and perfectionism is to ask a trusted colleague or mentor for their feedback. A reality check from a colleague who knows your work can go a long way toward quieting those thoughts and helping to manage the symptoms of impostor syndrome. And if you don’t have a trusted colleague who can give you a reality check, I would suggest a coach or mentor who can help you understand how you are relating to your work.
The most important thing is to shine a light on this in any way that we can. If you have felt the sting of impostor syndrome and/or perfectionism and/or burnout, look out for those colleagues who might be at risk or suffering. Talk about it. And keep talking about it, because chances are that someone you know, love, and/or work with is suffering.
How have you felt impostor syndrome? Talk about it in the comments.
Jessica Reeves is a nurse practitioner as interested in the well-being of her fellow clinicians as that of her patients — and she's on a mission to make the work world a better place to live. She writes, works, and lives in the town that holds the world record for most lit jack-o-lanterns (really). Follow her at jessicareeves.net. Jessica is a 2023–2024 Doximity Op-Med Fellow.
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