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. 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 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? 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 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 the types of factors that are associated with who goes into medicine, who holds leadership positions in medicine, and people's trajectory 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 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 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 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 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, 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 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. 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 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 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 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 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 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 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. 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 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 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 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 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 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 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 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 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 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 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 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 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.
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 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.
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.
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 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 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. 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 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 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 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. 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 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 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 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 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. 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 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 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 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 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. 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 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 administered it 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
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? 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. 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 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 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. 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 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.
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. 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? 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 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. 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. 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 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 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, 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. 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 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? 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 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 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. 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? 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? 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 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 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 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 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 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?
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 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 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 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.
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