impostor syndrome noun
Definition:
a psychological condition that is characterized by persistent doubt concerning one’s abilities or accomplishments accompanied by the fear of being exposed as a fraud despite evidence of one’s ongoing success (Merriam-Webster)
It is dizzying for me to think about the number of times in a day I am confronted by something I don’t know. The frightening rash I happen to discover while examining a patient despite a negative dermatologic review of systems (just moments earlier). The complaints of an episodic twitch. The troubling “wooziness” and fatigue that afflicts one patient after another. The various pains, both musculoskeletal and otherwise, described with the precision of “It just hurts.” And this is just a small sample that doesn’t even include all of the mysteries confronted in a rural geriatric Internal Medicine practice such as uncontrollable hypertension despite a half-dozen anti-hypertensives, the daily list of patients with incidentalomas on imaging studies, and the endless laboratory abnormalities that can’t be explained.
After doing some research on the symptoms and physical exam findings, I decide on a proper course of action consisting of additional testing and treatment in hopes of making a diagnosis. Unfortunately, many times the treatment fails and the testing only creates more diagnostic dilemmas. In frustration, I seek the aid of one of my specialist colleagues, only to find that frustration turn into failure due to lack of specialty availability in my rural community. As my self-doubt increases, my self-esteem fades and I question my abilities. At the same time that this internal narrative is playing out in my mind, I am continuing to see the concerned patient in my office and receiving phone calls from their apprehensive family members. This scenario plays out multiple times every week, sometimes every day.
Is it possible that I am among the 22-60% of physicians (Gottlieb, 2020, Med Educ) afflicted with impostor syndrome (IS)? This is especially concerning as IS is associated with higher rates of burnout, mood disorders and suicide. Several studies have found that individuals with low self-esteem reported higher levels of IS. Likewise, perfectionism was also associated with an increased risk for IS. Worst of all, the overall culture of medicine may perpetuate feelings of IS, as asking for help and not knowing the answer can be interpreted as signs of weakness.
However, in discussion with my 2 well-trained partners, I find them dealing with these same daily struggles. The common recurring themes expressed by all 3 of us include lack of access to specialty care, an unrealistic breadth of knowledge required in primary care accompanied by inadequate time and resources. They, too, describe a daily sense of foreboding related to the diagnostic challenges that day will bring.
A common scenario involves a patient who requires either the expertise of or a procedure by a specialist and that specialist is not available for months. At other times, that specialty is not locally available, requiring us to attempt to convince an octogenarian that a 90 minute drive into “the big city” is necessary. Many of our patients have barely strayed from their small hometown and do not share our sense of concern and urgency for their welfare. This is due, in part, to not only their lack of understanding of the intricacies of their medical condition, but also to their lack of insight into the training and limitations of a primary care physician.
Whether the patient procures a local specialist appointment several months in the future or a (somewhat) sooner appointment with an out-of-area specialist, we are still faced with what I have termed the “Little Dutch Boy” scenario. This involves my attempts to avoid medical disaster through feeble medical treatments that are the equivalent of putting my finger in a dike while awaiting definitive care by a specialist. A scenario that occurs far more often than would be expected involves the patient who refuses to travel for specialty care not available locally or refuses local specialty care. This may be for various reasons including mistrust of other physicians or concerns regarding additional costs in the form of office visits, copays and additional testing. This scenario results in the primary care physician assuming the position of the “Little Dutch Boy” permanently, attempting to plug the hole in the dike forever with no hope for relief.
I believe one quality of a good Internist is knowing their limitations and knowing when to seek the consultation of a specialist to aid in the diagnosis and management of complex diseases outside of the usual training for Internal Medicine. Additionally, another valuable attribute of an Internist is the ability to maintain healthy skepticism for a diagnosis in order to avoid missing alternative diagnoses. I have always viewed myself as having the ego strength to be able to admit when I can’t make a diagnosis and need to ask a colleague for help. However, the frequency with which that occurs, coupled with the increasing lack of availability of that help has almost certainly affected the robustness of my ego. With time that little bit of self-doubt seems to creep into other aspects of your daily practice of medicine and your psyche. This not only eats away at your confidence, but it also eats into your time as you begin to struggle with even the mundane diagnoses.
Despite 20+ years in a primarily geriatric rural Internal Medicine practice, there are still so many things I don’t know. I suspect that as medicine continues to evolve and advance that this will only worsen, and along with it, my self doubt. Those nagging thoughts that my fund of knowledge is seriously behind that of what it should be. Is this Impostor Syndrome or is this just a reflection of just how truly challenging it is to practice Internal Medicine in a rural setting? The answer to this question is just one more thing I don’t know.