Home of Medicine × Pre PACES: Tackling Imposter Syndrome

DR SAM WILLIAMS 0:01

Welcome listeners to this episode of the Pre-Paces Podcast, where I welcomed back the fantastic pair from the Home of Medicine podcast, Drs Amie Burbridge and Ben Lovell. This is something totally off the beaten track of PACES, but something that caught my attention, and that is the imposter phenomenon. All of us sort of bared our souls in this episode, and we all go deep into the hazards of imposter syndrome, detailing the definitions and what it means to each of us as individuals. We go through the common archetypes of imposter syndrome and most importantly, right towards the end of the recording, how we can manage imposter syndrome, both potentially as someone who might be experiencing it, but also what consultants can do to help their trainees manage these sometimes troubling thoughts. I appreciate it's not maybe directly applicable to paces, but I found speaking about this with Ben and Amy so eye-opening and interesting. I loved hearing their insights as two senior leaders in the world of medicine, and I hope you all enjoy this episode too. Have you ever walked onto a ward or been involved in a clinical discussion and thought everyone else knows exactly what they're doing, and I'm the one who has somehow slipped through the cracks. This pervasive feeling of being a fraud, despite evidence of past success, is what's known as imposter syndrome, or maybe more accurately, the imposter phenomenon. And for this episode, I'm delighted to be joined in another podcast in collaboration by the wonderful co-hosts of the Home of Medicine podcast. I'm delighted to welcome again Dr. Amie Burbridge and Dr. Ben Lovell. Welcome, Amy, and welcome, Ben.

DR AMIE BURBRIDGE 2:12

Thank you very much for having me on, Sam.

DR BEN LOVELL 2:15

Yep, me too. I can't remember the last time I was on the podcast. I think it was I think it was a good while. We were due for a reunion. I'm happy to be here.

DR SAM WILLIAMS 2:24

Excellent. Well, I'm I'm absolutely delighted to have you back on. And last time, if I remember correctly, it was Estec. Yes. Yes, it was. But we're discussing something very different today. And I'm thrilled to be discussing this topic with you both because, in my experience, this is always something which is somewhat of a taboo subject, imposter syndrome, especially in medicine, because for maybe clear reasons, doctors don't want to be seen as someone who doesn't appear to know what they're doing. And so I hope that throughout this episode we can explore what imposter syndrome is, why it's so common in medicine, how it can manifest, and hopefully by the end, give our listeners some tools to help to try and manage it in their day-to-day practice. So I think without further ado, let's get into imposter syndrome. So if we start off, if I just run through a bit of a definition. So I I guess goes without saying I'm not a psychologist, I've no training in psychology. This was just a topic which has been in the parlance, in the medical sphere for a little while, and I'm sure we'll talk about its applications in medicine as we go. Important to say as well, which I've experienced myself and I've seen it in others, and this led me to take a sort of deep dive into the literature of imposter syndrome. Although one thing I did find in the research was that a lot of experts actually prefer to call it imposter phenomenon because it's not a medical illness. Whereas a lot of the syndromes that we diagnose on a day-to-day basis are characterized by clinical features, but they tended to call it the imposter phenomenon. But I think, by and large, imposter syndrome is more or less how it's known commonly. And the definition which I've sort of amalgamated from a range of different sources is a feeling of inadequacy that persists despite objective evidence of success. And I sort of saw it nicely summarized in a three-worder, chronic self-doubt. Whilst uh, from the research that I found, it's not a clinical or formal diagnosis, it is linked significantly to mental health struggles, particularly anxiety, depression. And in our line of work, that can lead to things such as burnout, which is obviously so important to keep people well mentally and remain in work and mentally healthy. And I guess the one thing, as well, is that this can affect doctors of all levels, from medical students all the way through to consultants, which is why I think it's so valuable having two such esteemed guests on the podcast to speak so openly about this topic, because having um people in senior positions um demonstrate vulnerability and openness in discussing something like this will hopefully show the listeners that nobody's immune to this type of thought pattern and there's um ways of getting around it, which I hope we're able to do uh before the end of the podcast. And so I wonder if maybe one at a time, uh maybe maybe Amie, if we can start with you. Can we uh or can you think of uh an instance when you yourself have have felt a degree of imposter syndrome?

DR AMIE BURBRIDGE 5:36

Now, this very minute, yeah, you just described me as an esteemed individual. I'm like, what are you on about? Um, so I have chronic imposter syndrome or chronic imposter phenomenon, and occasionally I get acute imposter phenomenon. So it's a bit like kidney disease. You know, I've got it's always in the background, and then something happens and I get an acute attack of it. Um, that I have to identify the cause of the imposter syndrome or the imposter phenomenon, and then I try and uh investigate and manage it appropriately. But there's always an element of chronicity in the background. Aside from today, my first day at medical school was probably one of the most uh wonderful days, but also I didn't know what it was at the time, but it was feeling like a massive imposter because I got into medical school as a postgraduate. So I didn't get the A-level grades that I should have got, and I didn't get them because I spent my second year of A-levels doing things that I probably shouldn't have been doing, like going out, I was always working, I didn't really understand that I should be revising for A-levels, so I messed them up. So I did a different degree first, and I wonder if that has probably generated in me that imposter phenomenon from then, really, because I went to medical school and I was surrounded by all these incredible intelligent people who hadn't messed up their A levels, and I was like, Why am I here? I'm just this girl from Wolverhampton, you know, how what I shouldn't even be here, and um, it's still there now, you know. As I say, it's always chronic. And you know, times when I get invited to podcasts, I'm like, me, really? And when I've done conferences or talks, it blows my mind that people think what I have to say is interesting or important. So that's my experience, I guess, of imposter phenomenon.

DR SAM WILLIAMS 7:38

Thanks so much for sharing that, Amy, um, so openly. And maybe if I can share mine, and then Ben will come to you and you can tell us about your experience. But definitely my my experience most recently, so just for you know, total openness, I'm coming towards the end of my training now. I'm in my penultimate year. I'm actually out of programme at the moment, taking a fellowship, putting in pacemakers and defibrillators. But um, when I moved from a district general hospital to my local tertiary center for my um penultimate year of training, the step up in expectation, especially in a procedural specialty, the expectation to step into the lab and own the list and run the list and know the patients and know what you're going to do, know your approach and know all the technical aspects. As someone who, you know, had some experience, but certainly wouldn't wasn't at that point independent. I think that for me was the biggest stage of imposter syndrome or where I was most conscious of it, where I was being looked at by a consultant, by the nursing staff, by the other members of the team and the patient, and uh, you know, expected to step up to the plate. And I think that's something which uh I'm sure many, many medics will come across through their training, maybe when they enter their first clinic, or maybe their first shift is the medical reg. These are the types of situations where you can suddenly feel like a small fish in a very big pond and think, you know, am I the right person to be doing this right now? So I think, yeah, that's that's my experience of imposter syndrome in the most recent past. So, Ben, I wonder if we can come to you and if you can think of when uh your last experience of feeling like that was.

DR BEN LOVELL 9:19

Thank you. You're both talking about clinical work, and I guess that's how most people do in as a doctor, that's where you perceive yourself. It's is my clinical competence is not as good as I've decided it should be. And I I I've I've got a different perspective. It hit me differently. I I think people, you said people think about I don't belong here. Fraud, the F-word, I'm a fraud, people are gonna find me out. And it often occurs when people move in rotations. I mean, rotational medicine must be driving these thoughts. As soon as you get your feet under the table, you know the people in your team, you forge relationships with those people in your firm and your immediate surroundings, poof, off you go. You're now doing this in a different hospital, sometimes a different specialty. In acute medicine, one thing I loved about my training program was that they moved you around because they wanted you to spend six months as an ITU reg, right? Now you're gonna be six months of resp reg, six months, you're cardio reg now, you're taking all those referrals, six months, you're gonna be the care of the elderly. And I enjoyed that, but it it was odd. I remember on one occasion, I on my last day of um ITU medicine, I sent a referral to the respiratory team for review, and then my first day the next day, I picked up said referral as the respiratory, and I went off to review my own referral and ITU. And I laughed at it and I thought, this is this is bananas. Um luckily I was very well supported. But um I I didn't really get that imposter syndrome, the fraudulent feelings. I I did feel out of my depth. I felt out for my death, but it didn't make me feel in a way like an imposter. I often struggled, but I understood that as part of the job, actually. I thought, wow, this is a steep learning curve. I'd be honest. When I did my ITU rotation, I'd say, hello, I'm Ben, I'm an ST6 acute medicine trainer. This is my first day ever of ITU, so I'm gonna be there, I'll be the FY1 today, and you tell me what to do. And and I sort of announced it a lot, and I and I I kind of knew that it was expected. That gap I felt was not wasn't a I don't belong here. It was more of a I don't know this yet. But I knew I'd get it. And I think those are different things because I didn't actually feel fraudulent. I felt stressed and I felt out of my depth, but I knew I was going to get it with a very steep learning curve and it might not be easy. So I'd always push back a little bit on the idea that imposter syndrome is inevitable in clinical medicine, or if you don't experience it, it means there's something wrong with you or a psychopath or you're, you know, profoundly um, you know, a bit cocky. But there having said all of that, there was a time in my career where I did start to feel something closer to imposter syndrome. And interestingly, it wasn't during training. It was after I became a consultant, um, and I started moving to leadership roles, and I found that I couldn't blag that. I didn't have any training in that at all, really. Whereas moving to a new department or a new clinical team, I knew enough basics to make it work, to fake it till I make it. Whereas when I was sitting in leadership rooms, I was in very different rooms having very different conversations about strategy, about finance, about organizational priorities. People would ask me questions about um, well, how are you going to strategize for that over five years, Ben, including our, you know, our current financial deficit, bearing in mind that our relationship with NHSC means this has got to happen and that post is partially funded. Can you offset that with the research? Oh, and I'm sitting there going, oh my word. I am more out of my depth here in a much more fundamental way than I've ever been in my career. And that was the biggest experience I had with imposter syndrome. And maybe that's the closest I ever get to, I ever got to, I don't belong in. Although I knew in my heart of hearts I would get it. And I knew in my heart of hearts I had something to offer at senior leadership teams and and conversations. But that was that was um a real fish out of water moment for me. So I think reflecting on the whole thing, context matters enormously. I think sometimes what we label as imposter syndrome might be an incredibly rational response to being shoved into a new domain where you don't know anything, you don't know anyone without your usual scaffolding of experience. In leadership, I think I discovered that we were expected to arrive already fully formed, which is completely unrealistic. And the only way out of that I could find was finding mentors and saying to someone, look, I need you to explain this to me like I'm five. I will get it, but at the moment, I don't understand the first principles of what's being discussed right now. So someone's gonna have to take the time to do that for me out of the arena where the spotlight's on me, where I felt safe to ask inverted commas stupid questions. Did you have the same sort of thing, Amy?

DR AMIE BURBRIDGE 13:53

When I went into leadership. Yeah. I don't even think I am in leadership.

DR BEN LOVELL 13:59

You don't think you're a leader?

DR AMIE BURBRIDGE 14:00

No. So isn't that interesting? Maybe that's I've I have never seen myself as a leader. So maybe that is an imposter phenomenon in action. I don't know.

DR BEN LOVELL 14:09

I find that really interesting because I think a consultant is an incredibly important leadership role in terms of education, training, uh, patient safety, clinical effectiveness. And I've seen you speak at conferences, um, giving amazing talks that people are talking about over the lunch break afterwards, and they're saying, Did you see um Amy Burberg's talk about a case that changed my practice or or some or human factors or clinical reasoning? Wow, that was amazing. That's the kind of leadership.

DR AMIE BURBRIDGE 14:37

You look you're looking at me like I'm speaking a different language, but um it makes me feel really uncomfortable to hear that, and I think a lot of that actually imposter phenomenon. I wonder whether it stems from this is going into the psychology now a bit, Sam. Is it from childhood?

DR SAM WILLIAMS 14:53

I think there's going to be plenty that we can that we can identify with as we as we progress through the episode. Because as I mentioned to you before, we hit the record button, and we'll and we'll come to discuss this a bit later, is the is the common imposter archetypes, which um I I don't know about you guys, but a while back, probably I don't know, about 10 years ago, I got really into the personality types and I was doing all these online quizzes and saying, oh, you know, what's my type? Am I an INTJ? What am I, you know, the Myers Briggs and all that sort of stuff. Whilst it's not quite as I I guess um compartmentalized as that, and there's some clear overlap between them, the archetypes are so fascinating because I was able to not only see features in myself, but also in others that I worked with. And Amy, I was so so firstly, Ben, I think I I totally agree with what you said about rotational training. I think that is just a breeding ground for feelings of imposter syndrome. And how often do you hear someone rotate into a first job? And obviously, the foundation doctors or the uh resident doctors on the ward are so blown away by even the most basic things in a new rotation that of course that's going to be a shock to the system and feel as if they know very little compared to people who've been established there for a long time. And I think your other comments about feeling out of out of your depth in a totally different sphere than clinical medicine just demonstrates so well how um this spans across varying sectors, not just within clinical medicine. And so it's not just um doctors who can be a victim of this. But Amy, the one thing which I was so interested with what you said was about um your first day at medical school, because I was the exact same. Because where people come from their school or their A levels or their college or wherever they come from, it's probably more likely that they are a bigger fish in a smaller pond at that point, and they might be the prefect or the head boy or head girl, or they um, you know, might have been the top achiever getting the best grades, and then they suddenly walk into the medical school lecture theater on day one, and you find out more about these people, and you say, Oh wow, you've done everything I've done. Oh, but you're also the national fencing champion. Or, you know, you find these like ridiculously high achievers in other fields that have done everything you've done and more. And I think one of the things that leaves medics so prone to this is that we are naturally high, highly performing and perfectionist type individuals. And because medicine has such high margins for safety, or such narrow margins for safety, I should say, that the culture of perfectionism and the fear of getting something wrong, all of us know that sometimes the outcomes of missing that uh safety margin can be severe. And so I think it's elements like that that mean that our work within medicine can leave us prone to things like imposter syndrome.

DR AMIE BURBRIDGE 17:59

You get you you're absolutely right. You know, you go to school, well, it was or you mess up your radar like I did, and then I wasn't one of those high achievers anymore. Um, eventually I did get what I wanted and where I wanted to be. But I felt that when we were in medical school, you are very much sort of made to believe that you are the best of the best, you are the cream of the crop. You can't make mistakes because you can't make mistakes because you've never made one, you've never failed an exam. That happened to me. I went through medical school, I loved medical school, I did well at medical school. I started my foundation years and thought, hmm, maybe I was a little bit arrogant, maybe. Um, I felt like I was good at my job, people told me I was, and I didn't even see making mistakes or errors. I was never gonna make one because I'm great until I did, until I made a massive mistake. And that was in 2015. My life, my medical life, and my life is pre-mistake, post-mistake. It completely changed who I am. Since then, the imposter phenomenon, that's really where it started. I mean, it was it was there my first day at medical school, and then I overcame it, and then it came back with a vengeance, like a relapsing, remitting course. It was there, and it's been there ever since.

DR BEN LOVELL 19:19

I like hearing this thing about the um when you go to medical school, you just remind me of a couple of things. One, I've just remembered when you said that I've written a paper about this or or something. I'm just trying to find it. I think I published it in in medical education or medical teacher, something about doubt in first-year medical students.

DR AMIE BURBRIDGE 19:35

So now I feel like an imposter because you've even you've done a paper on it.

DR BEN LOVELL 19:41

It wasn't a paper. I found it, it was a letter to the editor. Everybody calm down. But it was 2005.

DR AMIE BURBRIDGE 19:47

That's me talking about it and you're writing.

DR BEN LOVELL 19:50

Yeah. How funny. I didn't think of that. You just said it now. It was such a long time ago. Many many first-year medical students experienced thoughts to say, I'm not good enough to be here, I'm never gonna get this, I'm a fraud, I've made a terrible mistake. I'm quoting my own work now. How big-headed is that? But I remember that um when you are a first-year medical student, you write, you come from such an environment where you're the first, first in school, the best in class. And when you're a medical school, all of your achievements, your A-level grades, your GCSE grades mean precisely zilch. You got three A's, so does every other person on this bench next to you. That counts for nothing. It's a great level. I remember the first exams we had, which must have been the end of the first term, and I got something like a satisfactory and a borderline. As a high achiever who was AAA all the way through school, that cut me to my core. Um, and I felt this is that probably the first exam I had not aced in a very, very long time. And I remember finding that very, very, very weird. And I imagine that's quite a common feeling when you go from being someone who's been, they know you don't get A's anymore, do you at GCC? You get nines or something or a one. I'm I don't know how they score it. But as you go through getting the top mark, I would say, and then going from uh to medical school where your top marks are the average, right in the middle of that bell curve where you've never sat before. That is an interesting thing. You have to make sense of and incorporate into your new identity as a young professional moving forward.

DR SAM WILLIAMS 21:09

Yeah, absolutely. And I again I'm going back to something which I I mentioned before we hit the record button, which we said we said we could have recorded a whole nother hour of conversation on. But I think what we're getting at really is that it the imposter syndrome, the message for the listeners is it's been almost bred into us throughout the passage of medical school. And before that, I think I think Amy, you're right that it could well go back, I don't know, so far as childhood, but certainly maybe early adolescence when people start thinking, oh, you know, I think I would like to be a doctor, I think I would like to go to medical school, but what do I need to do to do that? Oh, right. I need to hit the top grades in some of the hardest subjects and be right at the top of the tree to get there. And I think from that point, we are prone to putting pressure on ourselves for that. And the consequences of which can be Be severe as some of the consequences of imposter uh syndrome and the imposter phenomenon are detailed within the literature, and the effects on mental health are clear. Persistent self-doubt leading to emotional exhaustion. And one of the themes which sort of persists through the literature too is a lack of internal validation and leading to a dependence on external praise from uh other people or from you know institutions. You know, if you win a prize for getting the highest mark in Lesse, obviously you're absolutely thrilled with that. But I saw uh one of those quotes that sort of sticks with you that I made a note of from one of the papers, it said, it's not just that imposter syndrome causes burnout, it thrives in the same soil, which I thought was so poignant to, you know, almost compare them as bedfellows in a way. You know, hopefully before the end, well, towards the end of the podcast, we'll get into some of the ways that our listenership can manage some of the feelings that we've been uh talking about and the how that can happen all so easily when someone is uh pursuing or moving through a career in medicine. So moving into the common imposter syndrome archetypes or imposter phenomenon, we're gonna have to figure out you could say IP, but that means intellectual property rather than um imposter phenomenon. Um, some of the things that I came across in the literature were two things. One of them was the psychological mechanisms which underlie uh the imposter phenomenon, and then some imposter archetypes. So, but I wonder maybe you can comment on whether or not you feel any of these in your in your own practice that you've seen in yourself or maybe in others. But one of them we've talked about already is perfectionism, which cropped up again and again in some of the papers that I looked at. And perfectionism, success never feels enough, and it fuels self-criticism rather than confidence.

DR BEN LOVELL 23:58

I think as someone who's been in medical education for quite a while now, in my experience, perfectionism is sometimes the most troubling thing I notice in younger doctors because what tends to go with perfectionism, well, first of all, we need to admit you can't be perfect. Within human factors, there's something called the perfection myth, which is if you're super um fastidious and you're extra careful and you spend a lot of time, you will never make a mistake. And we know that simply does not work. Human brains do make mistakes. But I I've noticed that people who put who display perfectionism tend to be highly anxious, incredibly fearful of making a mistake, incredibly fearful of causing patient harm. They tend to stay late. They're still there at 6 p.m., 7 p.m. doing stuff that you think that was a five-minute job. They tend to come in early and they tend to not take any pleasure in their work and their achievements that they make in their work. And they kind of can be deaf to positive feedback. Um, a great job on this yesterday. Oh, I know, but I really should have done this. You know, it they they don't really hear positive feedback. And um, I sometimes are, you know, you're not always aware of someone's experiencing imposter syndrome because it's a very internal process. But perfectionism is an outward process as a behavior that uh I've seen trainees exhibit. And in my experience, it's been a really troublesome one. And it makes me worry because it's partly psychological, and I'm not qualified in the slightest to be digging around my trainees' psychological holes and working out what's going on there. And I want to be able to pull them through it. And uh I think it takes more than saying, relax, you're doing a great job, because that sounds quite hollow. But perfectionism and all the attendant behaviours that go with it are quite worrying for me as someone who trains a lot of doctors.

DR SAM WILLIAMS 25:43

Uh it's so interesting to hear you say that from a senior perspective, Ben. That that's I I wasn't expecting the word troubling to come out of your mouth, but that's so so fascinating that actually you you when you recognize that that's a cause for concern. It is.

SPEAKER_03 25:57

Yeah.

DR SAM WILLIAMS 25:58

And just going to the imposter archetypes, this is sort of they're twinned the sort of the psychological mechanisms with the archetypes, but one of the archetypes is the perfectionist. And one of the papers has a really nice table which outlines the sort of description of the behaviours, followed by the triggers which sort of produce the behaviors. And so the description for the perfectionist reads sets unattainably high standards, feels imposterism when anything is less than perfect, and the trigger is any small error or incomplete goals. So, and I'm sure we can identify with times that even small errors, you think, oh, you know, that's such a silly mistake, I shouldn't have done that. Or, you know, people handing over blood tests at the end of the day where they think, oh, you know, I should really have dealt with that. But, you know, these things sometimes are unavoidable, and it's important to acknowledge that too. I guess the other thing, which which is another psychological mechanism which has gone sort of hand in glove with that is the fear of failure. And that drives a sort of uh a feeling of shame-related anxiety with not meeting their own expectations. And maybe even the worst possible response to something like that would be someone in a senior position acknowledging that they haven't met the expectations, would be a consultant saying, Oh, you know, what do you mean you haven't uh seen this patient or requested this scan or made this referral? And so that for someone who has a perfectionist archetype is probably their worst, you know, their worst nightmare, really, to hear words like that when they sh feel they should be um achieving the things that they're setting out to do.

DR AMIE BURBRIDGE 27:24

You mentioned shame there, Sam, um, which for me is a very pervasive feeling, maybe. And I've described this before in that when I made my mistake, um, the the overwhelming emotion at that point, which I didn't realise at the time, was shame. And I guess the way that I would describe shame is it's not I did a bad thing, because I did do a bad thing, but it's I am bad. And I felt that I was a bad person, and that for me was shame. And I carried that around with me in a rucksack on my back, and eventually that rucksack got heavier and heavier and heavy, and the shame got heavier and heavier and heavier until I could barely function, I could barely walk, I couldn't go to work because the shame was overwhelming. I did use some of that to a positive effect in that eventually I reflected and went, come on, Amy, you can do this. Hence the podcast was born and my love of clinical reasoning and bias. But also, I think what came with that was a huge fear of failure again. It generated further imposter phenomena, and it's still there.

DR SAM WILLIAMS 28:42

Yeah, I think that's so uh so candid of you to share all of this, Amy, and and I hope that some of the listeners are identifying maybe with some of the things that we're describing. But towards the end, we will come into ways that we can manage these feelings, and hopefully that will provide some help for our listeners who might be feeling like this, but you know, it will probably uh equally help with any feelings that I have and and feelings that may persist um in any of us who are speaking about it. So I think it's so important for us to continue to talk about it. And I'm just going to move on to the second archetype, which is glamorously called the superhero. The superhero archetype overworks to prove worth across all areas of life and relies, it's a heavy reliance on external validation. They might do things such as over-prepare things as a means of protecting their reputation as a hard worker. And the triggers associated for the superhero is uh a failure to meet these self-imposed or impossible standards, which I'm sure has some overlap with the perfectionist. But I guess it's the superhero who comes in early, leaves late, tries to do uh finish the jobs list, um, come hell or high water. And as a result, their mental health suffers because they're not leaving on time, they're not having time with their family, loved ones, or their friends, and work becomes their identity and they lose more of the person who they are outside of work. I really found this is something, as you've described, Amy, something which goes up and down. But you know, I've certainly, when I've had, you know, a fair amount of workload, staying late on the odd occasion. But if you find yourself doing this persistently, you know, this might be an indicator that, you know, you might be committing too much to work. And one of the things which springs to mind for me as well is when we retire, who's going to remember that you stayed late? Who's going to remember that you did that extra discharge summary? Who's going to remember you stayed late to do that extra paperwork? And the people who will remember are the people at home because you weren't there to see them or speak to them or spend time with them. And so I think that's something important for our listeners to, you know, reflect on and think about in what they do.

DR BEN LOVELL 30:54

I suppose I can sort of facetiously devil's advocate that there's someone else who might remember that time you stayed an hour late, and that's the patients whose life you saved who had the cardiac arrest as you were clocking off your shift at the end of the door. But that was me being partially joking. I think there has to be balance. Um, I think doctors who who would ever who would say, Well, look, I don't care that my patient has had is suddenly deteriorated. My shift finishes now, so off I pop, someone else is a problem. And there's also the doctor who's late every day saying, Hi, I stayed late every day, Dr. Lovell. Isn't that great? And I have to say, I'm a bit worried about you. That's not great. There are other careers, I think, which maybe would reward that behavior. Wow, late every day in the office, really putting the hours in. We better give them a promotion. Medicine doesn't work like that. It will take from you. It will take from you and it will take from you. Um, but I think there has to be a balance, it has to be reasonable. And we all signed up for a job that sometimes things go wrong as you're putting your coat on. Um, but that shouldn't be happening every day or every week, or almost every month, really. Um, but there has to be a little bit of flexibility in the system. I think absolutely you're right though, the person who's late every day, I don't see any other outcome except for burnout. If you're doing two hours of unpaid work a day and there is there are five working days in a week and 52 working weeks in a year, there is no other outcome than psychological burnout and collapse, no matter who you are.

DR SAM WILLIAMS 32:14

Yeah, I'm in full agreement with that. There's absolutely no way of escaping that. I and I totally agree with you. There are obviously reasons to stay late at the end of a long day, um, cardiac arrest being one. But um there are also times when it's totally appropriate to um to obviously leave on time and not feel bad about handing over that blood test.

DR BEN LOVELL 32:33

And that should be most days.

DR SAM WILLIAMS 32:35

Most days. The on-call team are there for a reason, for sure.

DR BEN LOVELL 32:40

Yeah, that's what I always say. I mean, so much of what you're saying, maybe we can wrap it up at the end, Damien, but lies with us, lies with consultants. We we perpetuate or we change cultures where we work. And it's no good us saying things like, let working late again, I'd hate to be you, you know, we have to do something a bit more than that. And maybe there's a beer role at the end of this episode to talk about well, what do we need to do as consultants rather than telling resident doctors how they should behave in a busy, complex system? We should be talking about what power we have to leverage change. Mental note for end.

DR AMIE BURBRIDGE 33:12

And that is why you're in leadership, Ben.

DR BEN LOVELL 33:16

Oh, you've just cured my buttons. That kind of this kind of stuff is very easy. When someone puts a balance sheet in front of me with pound signs on it, I sort of glaze over and start making wibble wibble noises. But uh, this kind of stuff I find quite straightforward.

DR SAM WILLIAMS 33:30

Love it. Well, there are actually three other archetypes, but two of them are sort of uh complementary to one another. And so one of them is called the the soloist. They see asking for help as a weakness and need to achieve things alone to feel worthy. So these they think asking other people's uh advice or asking for help of the team is seen as a measure of weakness. And so the trigger for them feeling uh inadequate might be collaborating with others or um receiving um feedback from other people saying that wouldn't have been what they'd have done if they'd have done the same job themselves. This one maybe didn't resonate quite so much with me because I think in medicine we're an open-minded bunch and we do seek help where necessary, but I can certainly see it happening on the odd occasion of someone trying to do something for themselves. And I think the the situation that sort of resonated most with me is is I think in the sort of IMT1 to IMT2, IMT3 sort of phase when they're approaching the medical reg role and trying to make independent decisions for themselves. And maybe they make a decision which is, you know, acceptable and safe, but it might not be what the consultant may have done, which is just different. I'm you know what, I'm thinking of managing fast AF is really what I'm thinking of doing. You know, every consultant, even cardiologist included, will have a different way of managing fast AF. And some people will go for a beta blocker, some people will go for Digge, and on occasion, someone will go for amiodorone. Everyone will have a slightly different way of doing it. And it doesn't mean that there's no direct wrong way of doing it, but the soloist would probably feel uh a sense of criticism for having maybe been perceived as doing something wrong if they tried to do it alone rather than asking for help. So I don't know. Does that is that something that you identify as someone who someone who is who's tried to do something by themselves and maybe felt the need to do it by themselves to prove their worth?

DR BEN LOVELL 35:23

Whenever I induct new medical registrars, which is part of my work, they rotate in, and then before they lead the take in my hospital, I give them a face-to-face induction just to orientate them and tell them what's what. We all got our own way of doing things, different systems and pathways. And one thing I say is that between this time and this time, the FY1 will be managing this area over here, the ward area. And I say, and you'll experience FY1s who call you a lot for every single decision because they haven't quite got you know their confidence up. And that's fine. I said, but also be mindful of the ones who never call you. That would be unusual. Um and that's when you sort of call them and just say, Hi, I'm Bob, I'm the med reg today. Haven't heard from you in a few hours. I'm assuming everything's okay, but is there anything you need from me? Because I guess I've learned over time that the ones who never call for help, that's not just because they don't need it or because things haven't gone a little awry in their clinical area. There's something else going on there. I see it a lot in doctors, um, excellent doctors who come to us from other cult other countries, other healthcare systems. Um, they sometimes they seem less keen to flag things up to me. And then so my role is to say, hi, I'm Ben, I'm the consultant, I'm sitting in that little office over there, um, and that is my patient. That's my name above their bed. Please come and let me know if there's a deteriorator, things go wrong. I don't want to find out at the after action debrief because there's been an a cardiac arrest call. Come again. And and I even after that conversation, sometimes I feel there's a reticence, people to come and tell me. There's a hierarchy, there's sort of cultural norms at play, there's a few things going on there. But again, I'm always slightly wary of the doctor who never needs help because that can't be reality. We all need help.

DR AMIE BURBRIDGE 37:08

I think I think people probably fluctuate through the different archetypes at various types of their career. And I've certainly seen people in different roles adopt different archetypes. So maybe it's perfectionism in one, the fear of failure in another role, the soloist role, maybe in a new role, maybe going into leadership or education that's you're not that's not normal for you, and you feel like, well, I've got to prove this on my own. You know, I've got to show them I'm gonna do this. So I do think that can change um throughout your career. Um I guess with being a soloist as well, because I think this is something that I've probably done as well, it's about proving yourself with perfectionism and failure. It's about I'm not good enough. Soloist for me is I can do this. I'm gonna prove to you that I can do this, and I don't need anybody else. I can run this cardiac arrest, I can run this take, you know, I can do all this by myself because I don't need anybody else. And I think that's something I know I've definitely done that. Probably less now as I get further on in my career now, much more I need help. But maybe again that's come with wisdom, is that I'm much more open now for asking for help. But certainly a few years ago, maybe early on in my career, it was trying to prove myself.

DR SAM WILLIAMS 38:30

Yeah, and just to compliment again, uh this is the second archetype, which was sort of there's a decent amount of overlap with this, but the second one is the natural genius. So this person measures the ability, measures their own ability, sorry, by the ease and speed of their learning, and and the the triggers for them are when they struggle with tasks that require sustained effort and they don't master it first time, which I think just mirrors almost exactly what you were just uh uh just trying to get into.

DR AMIE BURBRIDGE 39:01

Yeah, it's like um POCUS. I mean, I'm always talking to Ben about POCUS, point of care ultrasound. But I've really struggled with POCUS. So maybe the natural genius that I clearly am is coming out because it's drove me mad. You put a probe on and like, look, it's the liver, and I'm like, no, it's not, it's a blob. It's taken me nine years to go from starting thoracic ultrasound to 2026 to get POCUS.

DR SAM WILLIAMS 39:39

There's only I think there's only one archetype left, which I think is sort of crosses all the boundaries, really, but they've called it simply the expert. This person believes that competence depends on knowledge and hoards qualifications and fears being found out. And I think we've mentioned that a couple of times throughout the recording so far, that feeling of being found out. And so any gap in knowledge or um blind spot they might have is their kryptonite. You know, they they hate being the person who doesn't know or doesn't have the certificate or tries to attend every single course going, you know, it's not certainly not no um bad thing to attend courses and try and improve yourself, but the person who tries to just be across absolutely everything is maybe the person who's trying to be the expert. Although I have to say, I don't uh uh again, sort of similar to the soloist. I don't think I've seen too many experts in my time, but I think they they they must exist somewhere.

DR BEN LOVELL 40:39

I think I sort of flirted with that. I remember Amy, I told this story on a podcast episode we did a long, long time ago, right near the beginning. I made a I made a real mistake when I was a med reg once, and um it was with a pregnant woman, um, the patient, and and I really, I really made the wrong call and and it really haunted me for a while. And I decided it was because I it's because maternal medicine or you know, treating acute medicine in people who happen to be pregnant, that to me was a weak spot. And I decided I am not gonna be avoidant of this, I am not gonna let this wound me, I'm gonna be the expert in maternal medicine, so there, and off I went, and I did I sat the DRCOG exam and got my diploma in Obs and Giny, which I don't think I've used very much since then. And we agreed on the podcast it was a slight overcorrection to in the face of adversity, but I had to conquer this somehow. And the way I knew to conquer it was exams and academia and knowledge because that was my identity up till that point. That was what I was gonna do. I'm gonna frame this thing, and that that means I could never, I could never do a similar mistake again. This was all over 10 years ago now when I was a register, but maybe that was me being a little bit of the expert with a capital E or trying to be one and protect myself, my ego, my psyche, protect my patience by accruing as much of knowledge in one area as I possibly can. Because that means I could never make the same mistake again because I had the certificates, which I now see was is not quite uh how life works.

DR SAM WILLIAMS 42:08

So we've gone in detail through a number of the archetypes involved in imposter syndrome, but now it's getting to the really important bit where we have to talk about how to manage and overcome these feelings of uh the imposter phenomenon. And I think the first thing, which is just so important, which hopefully we've tried to do today, is to acknowledge the problem and talk about it with your peers and your colleagues, which hopefully we are doing uh for our listenership today. And so normalizing these feelings in medical spaces or the medical sphere, hearing respected senior colleagues talk about their experiences reduces the isolation that some people may feel when they talk about um this type of problem. But beyond that, what some of the some of the things that I found through my bits and bobs of research, one of the things is reframing the mindset. And so, Amy, we can go back to maybe the example you gave of sitting in the medical school uh hall where everyone here is brilliant and I'm not, was the sort of thing that came into your head. And if you might reframe it and say, everyone here's brilliant, what an opportunity to learn or what an opportunity to be the best version of myself. That was one of the things that I came across through my uh through the bits of research. So reframing the mindset to think, you know, anyone at any stage of life, that might be me going into my tertiary center cardiology post thinking, wow, uh, I'm expected to do these pacemaker procedures. What an opportunity to really take the ball by the horns and get going with the with the procedures. Have you ever felt the need to reframe your mindset or ever thought about it in those terms?

DR AMIE BURBRIDGE 43:40

Never. But I've tried to reframe other people's mindsets. So I think I'm quite good when people come to me and say, Oh, I'm terrifying you know, they have the imposter phenomenon. And I'm probably I like well, I hope that I tell people, no, you're great, you know, you've got you do this, you Of that, these are all amazing, like reframe it for them. So I probably find it easy to reframe those imposter phenomena for others rather than myself.

DR SAM WILLIAMS 44:09

It's interesting you can find the scope to help improve others, but then trying to help yourself is so or some some of us find it so challenging.

DR AMIE BURBRIDGE 44:17

It's it's icky, like it feels a bit weird. Um, but I also believe that actually, by what we're doing now, by being open and vulnerable, is incredibly powerful. And sharing stories of shame, vulnerability, failure hopefully opens the floor to others to go, actually, that's me as well. And actually, I felt like that as well. So role modelling that vulnerability for me is incredibly important. I know that some people don't agree with that, um, and they believe that role modelling vulnerability is a negative thing, and that we should never show our vulnerable side because we are professional doctors. You know, we should always be those upstanding members of the community. But I really believe in fostering a psychological safe space.

DR SAM WILLIAMS 45:03

Yeah, absolutely. And so just going through a couple of the more practical techniques that I managed to uh extract from some of the papers. So one of them is uh self-awareness. So identifying the patterns and triggers to your feelings of negativity and feelings of being an imposter. So just going back to some of the things we discussed earlier, so making small errors or handing over that blood test in the evening, maybe just you know, a bit of a reality check and saying, you know, it was a single blood test. It's not a disaster to hand it over. They're on call until nine. They've got four hours to look at a CRP result. You know, re and again, that's an example again of sort of reframing, but also just giving yourself that reality check and identifying the types of things which can trigger those feelings. Um, another one that came up was positive affirmations. Have you ever used positive affirmations in any areas of your life? Do either of you have any uh experience with using those?

DR BEN LOVELL 46:01

I don't, but I know a lot of people who do. I I think it works for people. The idea being if you tell your brain something enough times, it will start to believe it. Um, I don't know if I have a susceptible brain like that. I I've sort of dabbled with it over time, but I I keep forgetting to do the wretched things. But I think if you're able, if you've got the um self-discipline to do them all the time. And I think from what I know is that positive affirmations need to be quite generic and positive, i.e., you couldn't say, I will not make a mistake today. I will not make a mistake today because that's full of knots and mistakes. It's got to be things like, I'm I I'm making this up, I am a flexible and adaptive, hardworking doctor. I'm a flexible and you and when you say enough times, the brain starts to make a new sort of neural connection, a pathway, and that actually becomes part of reality. So I know when they are from a hand's distance, arm's length distance rather, but I haven't really engaged them so much myself.

DR AMIE BURBRIDGE 46:57

There's also the power pose. So um my friend swears by the power pose. So before you're going to go into a meeting or an interview or a ward round, you stand and you either strike the Superman or you neither I've got this. Like you, it's a I know it sounds a bit ridiculous. But I did it before I went, I had an interview in January of this year, really big interview. And I was in the bath in the toilet doing these power poses for about three minutes, and there was one toilet, and when I came out, there was a queue. I was like, they were probably thinking, what should we be doing there? And I was pulling power poses.

DR BEN LOVELL 47:35

I got the job, so you know, maybe it did work, but um I think only podcasting was a visual medium and they could see what we see right now.

DR AMIE BURBRIDGE 47:44

But it was it's reframing the mind, isn't it? It's resetting those circuits within the brain, which is what therapy does, you know, that's what therapy's there for. Not saying that power poses are therapy, but you know, it is a form of you know behavioral therapy that can help us change.

DR SAM WILLIAMS 47:59

Just reflecting on what you just said there, Amy, one of the things is adopting a growth mindset. I don't know if you've heard of that before, but I read a I read a book not so long ago called Mindset by Carol Dweck. I don't know if you're familiar with that book. It's just called Mindset. Really excellent, excellent book where she describes she's a psychologist in the US and um helps you move your thinking from a performance-driven mindset to a growth mindset. And so I definitely recommend if if any listeners are identifying with what we say, then the book Mindset by Carol Dweck, that's D-W-E-C-K. I can strongly recommend that for you. Um, another one, especially for the uh imposters among us or the pseudo-imposters among us who struggle to believe their own hype, is keeping a log of success. So acknowledging the positive outcomes or acknowledging the or making a record of wins, I guess, in your career to, I guess, give some credibility to your to your feelings. And I don't know how that would work in acute medicine, but it might be something like, you know, you could think of, oh, just think of the numbers of pay, you know, you always remember the patients where you made a mistake because it happens so infrequently. But you think of, you know, in terms of your diagnostic accuracy for the other 90 plus percent of patients who you take excellent care of, you know, that's the success log, which is sort of unspoken about. So a success log, I thought was a nice idea, but maybe just something too um, maybe arduous to put into practice, but something to always just consider.

DR BEN LOVELL 49:32

If I can um jump in then, just to throw a footnote, because we said um, so what sort of things can consultants do or leaders do in any Medregis, you know, in who are leading on a shift, particularly out of ours, what can we do to try and help people we're working with with their imposter symptoms? And I've been writing down a couple of things as we've gone through. And one thing that um I found in my own experience is that people who do experience imposter phenomena is that they're often comparing themselves to people who are way ahead of them, um, like sometimes 10 years ahead, sometimes five years ahead, sometimes three months ahead. Or why aren't I not as good as them? Hang on a minute, they've been here a bit longer than you, and this is your first week. I think our role is to help them recalibrate a bit and say, this is what competence looks like at your stage. And this is what I need from you. You are delivering this, actually. So you're well on track. I'm really pleased, and you should be as well. That's one thing that that came to me because I think comparison is often uh a catalyst or at least an enzyme in the imposter syndrome process. And sometimes those comparisons are way off, way, way off. And we need to just recalibrate and say, hang on, if you're gonna compare to anybody, compare to someone else who's who's all who's only two weeks into role, like you are at the moment. The other thing I was thinking about is letting you someone mentioned letting trainees make mistakes as long as it doesn't result in patient harm. This reminds me of a paper I read a while ago. I've looked it up, it's got a brilliant title. How about this? Is for a title of an educational paper. Whatever you cut, I can fix it. Clinical supervisors interview account of allowing trainee failure while guarding patient safety. And it was from a surgical point of view, and it was about how surgical trainers sometimes, in a very supportive way, they see something, a mistake about to happen. And as long as it's not going to harm the patient, they let them make it. And then they say, okay, how did that work out for you? Next time, try this. And I wonder if there's a role for us in doing that and allowing safe failure. We think about imposter syndrome and that absolute rigid terror of failure. Can we make failure happen in a way that doesn't really have any repercussions? But since we agree that failure is inevitable, maybe we can give it to them in an environment where it doesn't actually cause massive self-psychological damage or of course patient harm because patient safety is number one. And the last thing is what Amy's talked about, which is talking about our mistakes. The one brilliant, one of the brilliant things about the Society of Acute Medicine Conference, they always have the session about the biggest mistake in my career by consultants, and it's always the most attended session. Trainees need to hear about us making mistakes. They love to hear of us making mistakes. And then it's not from any sort of, you know, I want to see that a disaster unfurl, it's because they need to know that it happens. On our podcast, we talk a lot about the power of I don't know as a consultant. The words I don't know just fly out of my mouth now on a post-tag ward round. Because I want them to see that I'm not all powerful and all-knowing. Um, and that's okay. So I don't know. And sometimes if I do make an error, I tell people about it. We talk about our mistakes on the podcast because I want people to know that perfection myth is an absolute myth. And if you've idolized someone and think, well, they don't make mistakes, they're perfect, then you've miscalculated, and it's gonna cause you harm down the line.

DR SAM WILLIAMS 52:42

I love those, um, I love those suggestions, Ben. I think that's so important. And especially when it comes from, I think sometimes as consultants or as senior, I guess, role models to um resident doctors on the ward, I think sometimes we can even underestimate how much impact we can have, even in the smallest comment that we might make to someone on any given day. And I think it's so important, even just a very small thing, just to go one-to-one to someone and say, you know what, you did absolutely brilliantly for that patient today. That's absolutely brilliant. Send me a mini-kex, send me a CBD, formalize it in the portfolio, because the most valuable reflection is that which is genuine and uh applicable to um real experiences that the residents go through. So, yeah, absolutely couldn't agree with you more, Ben.

DR AMIE BURBRIDGE 53:31

Final thing from me as well is that if what I always remember, I did a shift as a registrar, uh, really busy, busy on take overnight. And I got an email from one of the charge nurses to say, Well done. So now if I see something at work, it's really nice if somebody comes up to you and says, You did that really well. But actually, to aside from the mini keks and that tick box portfolio, isn't it lovely when you get a thank you card or an email or just something that's a little bit more personal because the ePortfolio is not very personal, but when you get an email or you know a card and say, Thank you so much, I think that means a lot. And it actually doesn't take that much effort, and that can really do something to boost an individual's sort of confidence, but also it's quite nice for us as well. So I think we need to harness that a little bit more, spread the love, be kind.

DR SAM WILLIAMS 54:27

Yeah, absolutely. I definitely couldn't agree with you more. And I guess one of the one of the very last things that just comes into the sphere of managing and overcoming these imposter feelings are is support and mentorship from the people you work with. And that can be speaking to uh your supervisors, your clinical and educational supervisors, speaking to your peers, speaking to registrars or other seniors that you work with on a day-to-day basis. And I think, as Ben has outlined really nicely, it's also on us to help the resident doctor workforce feel valued and yeah, I guess emphasize the difference that they make on a day-to-day basis, which is so often underestimated.

DR AMIE BURBRIDGE 55:09

Oh, absolutely. Absolutely. It's um one of the most important things I think as supervisors, as senior registrars, consultants, that's what we need to be doing is yeah, being thankful.

DR SAM WILLIAMS 55:22

I think that's a really nice note on which to end it, Amy. And so I think just to hopefully package up what we've gone through today, that imposter, the imposter phenomenon is a common, understandable, and manageable problem that we see in medicine. And awareness of the issue and open discussion with your peers, your colleagues, your seniors are key to helping manage it. And if this resonates with you, please talk about it, write it down, and remember that you belong here. You are not alone. There are other people who are experiencing just the same as you, albeit they might not be saying it out loud. And I hope that this podcast has given you um some confidence that uh you're not alone in feeling the feelings that you feel. And it's been an absolute delight, though, to have uh have back um Drs Amy Burbridge and Ben Lovell. Amy, thank you so much for joining me on the podcast.

DR AMIE BURBRIDGE 56:19

Thank you, Sam. It's been wonderful. I feel like a therapy session.

DR BEN LOVELL 56:24

Ben, thank you so much for joining me. Oh, thank you for having me, Sam. It's been amazing, and we we do it again.

DR SAM WILLIAMS 56:30

Yeah, absolutely. But listeners, that is just about all the time we've got for this week's show. As ever, please don't forget to like, follow, subscribe, or leave a five-star review wherever you get your podcasts. Get in touch via the website prepacespodcast.com or via the email, which is prepacespodcast at gmail.com. And as ever, if you want to go above and beyond and support the show, you can do that at buymiacoffee.com slash prepaces podcast. But for now, we're just about out of time. Thank you so much for listening. I've been Dr. Sam Williams, and we'll see you next time on the Pre Paces Podcast.