Abstract
Physicians experience impostor phenomenon when they attribute their success to luck and fraudulence rather than ability or competence. They also experience workplace violence, including sexual and nonsexual harassment, discrimination, microaggression, and assault, among others. Using Weiner's attribution theory, this qualitative study interviewed US-based physicians experiencing impostor phenomenon to investigate its connection with workplace violence. Two research questions were examined: What are the different forms of workplace violence reported in medicine? How does workplace violence contribute to impostor phenomenon? Interested participants responded to an advertisement about a national study examining impostor phenomenon at a US-based medical conference (convenience sampling). After the interview, many participants shared the study information in their professional and social network, encouraging others to participate (snowball sampling). Data were analyzed using constant comparison and analytic induction. Sixty-three physicians completed the initial survey and were all invited for the interview. Thirty-five out of them interviewed and the rest did not respond to the invitation email. Of those 35 physicians, 19 (95% women; 79% white) between ages 30–59 years specifically reported experiencing impostor phenomenon when facing physical, verbal, racial, and/or gendered violence. Gendered violence included both gender-based assumption of position or competence and gender-based harassment. Impostor phenomenon occurred when women and men were treated differently; participants questioned their competency or belonging; and women saw fewer women physicians around them and other women perpetrating violence. The impostor phenomenon was attributed to an external experience of violence perpetrated by people of all genders and relationship types, including seniors and peers, physicians, patients, and nurses. Participants often could not control violence perpetration and instead, internalized the experience as their fault and lost a sense of belongingness at work. Findings, while not generalizable and based on a small sample, show that impostor phenomenon is not only affected by individualized internal mechanisms, but external environmental factors as well such as experiencing violence or seeing it happen to others. Future research should explore the role of race/ethnicity, sexual orientation, gender orientation, socioeconomic status, and generation status in shaping such experiences.
Introduction
Medicine is a highly competitive and demanding field. Both medical students (Holliday et al., 2020; Houseknecht et al., 2019; Shreffler et al., 2021) and physicians (Addae-Konadu et al., 2022; Gottlieb et al., 2020; Leach et al., 2019), even in their advanced careers, feel incompetent and question their achievements (LaDonna et al., 2018). They experience impostor phenomenon, attributing their success to luck and fraudulence rather than ability or competence (Clance and Imes, 1978). Impostor phenomenon is stigmatic and is correlated with reduced self-compassion or self-esteem (Rosenthal et al., 2021), burnout (Dyrbye and Shanafelt, 2016), and distress (Lawton et al., 2020).
It is also an affective response to adverse environments, including workplace violence (McElwee and Yurak, 2010) perpetuated by systemic inequities. This includes gender gaps and the underrepresentation of women and minorities in leadership positions (Mullangi and Jagsi, 2019), with poor initiatives to recruit, retain, promote, and advance women in medicine (Carr et al., 2017).
The impostor cycle (Clance et al., 1995) shows that those with impostor feelings start a project or task either overpreparing or procrastinating. They have self-doubt and anxiety. Eventually, when the task is successful, there is a sense of accomplishment or relief. However, they ignore the positive feedback received, attributing their success to luck or effort, but not competence. This is followed by anxiety about being a fraud or impostor. The cycle repeats with every new task or accomplishment. Ironically, impostor feelings typically peak after any success or accomplishment and not after a failure (Clance et al., 1995).
Impostor-like behaviors can be explained using Weiner's (1972) attribution theory. Individuals make meaning of their achievements and failures through three factors: locus of control (internal/within their control or external/outside their control), stability (whether the cause remains stable or not over time), and controllability (whether the cause of their success or failure can be controlled). These attributions, in turn, influence motivation and behavior.
Workplace violence includes “a spectrum of unacceptable behaviors” like abuse, discrimination, and assault that threaten the health, well-being, and safety of workers (International Labor Office and World Health Organization, 2014). It broadly includes bullying, verbal and physical abuse, threat, sexual harassment, and sexual abuse (Boyle and Wallis, 2016). Sexual and sex-based harassment from peers, professors, and patients are rampant in medicine (Frank et al., 2006; Hinze, 2004; NASEM, 2018; Vargas et al., 2020). A meta-analysis of 51 studies shows a high prevalence (∼60%) of discrimination (especially race-based and gender-based discrimination) and harassment (especially verbal harassment) experienced by medical trainees from consultants, patients, and their families. Women trainees experience sexual harassment more frequently than men (Fnais et al., 2014). In a survey of ∼2000 medical students at one school, residents and faculty were reported as the primary perpetrators of verbal and physical harassment (Fried et al., 2012).
Among medical school faculty, women are more likely to report harassment than men; this includes sexist remarks, unwanted sexual advances, and subtle or overt, coercive advances to engage in sexual behavior (Jagsi et al., 2016). Yet, frequent nonreporting of sexual harassment occurs due to stigma, fear of retaliation (Bates et al., 2018), higher ethical or moral distress (Pololi et al., 2020), and the belief that harassment is a part of culture in medicine and reporting it is a waste of time (Freedman-Weiss et al., 2020).
Impostor phenomenon and workplace violence have been studied among women in science, technology, engineering, and medicine (STEM) (Aycock et al., 2019; Chakraverty, 2022; Chakraverty and Rishi, 2022). Harassment and micro-aggression happen through othering, poor belongingness, poor identity development, and race/ethnicity-based stereotyping among Latinx doctorates (Acosta, 2020) and black doctorates/postdoctorates (Chakraverty, 2020) who also feel like impostors. The current study examined connections between workplace violence and impostor phenomenon in medicine, an understudied area. Research questions examined were the following: (1) What are the different forms of workplace violence reported in medicine? (2) How does workplace violence contribute to impostor phenomenon?
Methods
In 2017–2018, the author conducted a US-based qualitative study to examine impostor phenomenon in medicine. Data were collected and analyzed according to IRB guidelines and regulations at Washington State University. Following IRB approval (No. 16159-001), the author advertised the study at the 2017 Association of American Medical Colleges (AAMC) Annual Meeting (Boston, MA) by distributing flyers with a website link hosted by her university to solicit participation. Interested participants responded to the advertisement by taking an initial, short survey (convenience sampling) (Sedgwick, 2013). Medical students, residents, physicians, and faculty at US medical schools who felt like an impostor and could articulate their experiences were eligible to participate, irrespective of their demographic characteristics such as age, sex, race/ethnicity, geographic location, and position.
Data were collected sequentially through online surveys and semistructured phone interviews following informed participant consent (Chakraverty et al., 2022). The anonymous survey (∼5 min) included demography questions and twenty items from the validated Clance Impostor Phenomenon Scale (Clance, 1985) used with permission to check the factor structure of the scale (Lee et al., 2022). All those who completed the survey were invited for a 30- to 45-min interview. Those interested replied to the author by email. The author immediately scheduled an interview based on mutual availability. The author conducted all the interviews, audio-recorded them with permission, and transcribed them through a transcription company. Participants were not explicitly asked about whether they had experienced workplace violence.
However, they were asked about their general training and workplace experiences; family background; and specific instances or situations that made them experience impostor phenomenon. Participants shared the study information in their professional and social network (snowball sampling) (Naderifar et al., 2017). Participants did not receive any payment.
Transcripts were de-identified; narratives of workplace violence were analyzed using constant comparison (Glaser and Strauss, 2017) and analytic induction (Pope et al., 2000; Thomas, 2006). Interviews were coded with periodic input from a faculty colleague from the college of medicine trained in qualitative research. Codes were consolidated into themes and presented with representative quotes using pseudonyms. Multiple steps were taken to improve trustworthiness of the study (Holmes, 2020; McGrath et al., 2019), as described below.
Before each interview, the author went over the general aims of the study, read aloud the consent form (that was emailed to the participants earlier), declared having no conflict of interest, and asked for consent before proceeding (initial debriefing). The author took reflective notes for each interview to acknowledge any biases, remembering that her worldviews as a woman pursuing medical education research could influence her interpretation of narratives (positionality). Following transcription, participants read their transcripts to add, delete, or edit text to reflect accuracy and hold agency (member checking). Interview questions were formulated, and data were analyzed in consultation with a faculty colleague who actively pursues medical education research (expert consultation).
The author was mindful of participants' demographic background (gender, race/ethnicity), aware of the low participation of men (mindfulness). The interviews are confidential and contain sensitive information that may identify the participants. The consent form that participants signed stated that their data will not be shared with members outside the research group (data availability).
Ethical considerations
Before the interview, the author clarified that all questions were voluntary, participants could take a break or stop the interview any time, and anything they shared would be treated confidentially. The author e-mailed all interviewees to ensure that they did not experience postinterview anxiety. During the period of data collection, one participant asked to remove and destroy their transcript after the interview was conducted. The author destroyed the interview recording and transcript immediately.
Results
Sixty-three physicians completed the initial survey and were all invited for the interview. Thirty-five out of them interviewed and the rest did not respond to the invitation email. Of these 35 physicians interviewed, 19 voluntarily shared, unprompted, that they had experienced one or more forms of workplace violence (Tables 1 and 2). This article analyzed narratives about workplace violence and impostor phenomenon from those 19 interviews.
Participant Characteristics
OBGYN, Obstetrics and Gynecology.
Different Forms of Workplace Violence (First Research Question)
Forms of workplace violence in medicine
The first research question found four forms of workplace violence, both sexual and nonsexual.
Theme one: Physical violence
This included sexual harassment and physical assault, including being touched, grabbed, or rubbed without consent. Women who described themselves as short shared sometimes feeling intimidated when physically surrounded by taller, male physicians. They watched male physicians, especially in higher positions, throw medical equipment such as scissors, scalpels, and other sharp objects when angry or acting assertively. They questioned if they belonged in such unsafe, abusive workplaces. Caroline shared:
Occasionally, surgeons throw instruments at staff in the OR [operating room] if someone made a mistake or something went wrong. It's scary, because it's a biohazard and it might be the only instrument that's clean for an emergency surgery. It's a lot of entitlement, the feeling that, “Everything should go right because I'm the surgeon.”
Theme two: Verbal violence
This included frequent yelling, belittling, verbal targeting, and being demeaned by male attendings and residents, also described as the “general culture of medicine.” Anna (an attending) described being yelled at by an old, male radiologist saying she should not read a patient's chart because she was not qualified. Lucy reported harassment by a senior male doctor who “would constantly come into my room in the middle of procedures while patients were still awake and yell at me things that were highly inappropriate.” Elizabeth added, “You will have someone constantly screaming and cussing you out while you're operating. We learn and train through being embarrassed in front of people.”
Older men (including patients and, more frequently, colleagues) made sexist and sexual comments. Women physicians were judged for their clothes, looks, and makeup, and told how to dress up by male residents who commented on “women's place” in medicine. Caroline shared, “A male resident, so blatantly sexist and entitled, told me, ‘All women should do their hair in the morning.’” Some participants reasoned that many male surgeons yelled because of stress and perennial sleep deprivation. Harriet found working with male neurosurgeons and cardiac surgeons particularly difficult. “They yell, scream, and are really rude to women all the time. They're doing really difficult things in the middle of the night.”
Theme three: Racial violence
This included race-based microaggression. Grace, the only black physician in this study, remembered her third year of medical school when she was handling a case of a fatal gun wound in the operating room with an attending and two residents. She answered the attending's question about the name of the muscle injured (the subscapularis muscle) correctly, upon which, the residents shouted and mistreated her.
I got crushed by these two upper-year, white residents who were probably 5–6 years ahead of me in training. They didn't remember basic anatomy. But they had some kind of power. It shifted my belief about myself. I suddenly developed this doubt, having a quieting of my voice. “How dare you speak out and think that you know what's going on, think you're better than me?” It confirmed that I may not actually know what's going on when I do.
People made certain assumptions about Grace's race. “I'm African American so people look at me and already have this assumption about me. It happens all the time.” Recently, when entering an employee-only elevator at her hospital, a housekeeping person asked her to take the visitor elevator. “I said, ‘I'm actually a physician here.’ ‘Oh, you are?’ I got on the elevator and said, ‘yeah, hard to believe, right?’ I've been an attending for over 10 years! Those constant little microaggressions make me question myself.” She further elaborated, “The white male medical student, they assume he's the doctor. The kid is like 10–15 years my junior in age, it's a constant struggle internally.”
Rick described numerous situations where no matter how quickly he came up with the correct diagnosis for patients, he was always criticized about his clinical decisions and his diagnosis was dismissed by faculty. “It was always the two white male students who were preferred by these faculty members. The questioning and criticisms I received were more intense compared to the preferred kids who were given an easier ride. This is microaggression.” He experienced microaggressions early on, by the chair of his department. It made him wonder if he was in the right place.
Theme Four: Gendered violence
Subtheme 4a: gender-based assumption of position or competence
It was reported that many older, male patients and their families, staff, and male physicians assumed that male students and interns, especially when white, tall, and with a beard, were physicians. However, women physicians were assumed to be nurses, pharmacists, nutritionists, janitors, phlebotomists, dieticians, physical therapists, medical students, college students, or in one case, even a male physician's daughter. This happened even when women were dressed as physicians. Nurses and patients called them (but not the male physicians) by their first name. They were expected to be acculturated into gendered roles, be humble and community oriented, while men were assumed to be strong, confident, and independent.
For example, Julia reported that patients used terms of endearment when interacting with her (e.g., “honey,” “sweetie,” “hey girl”). She stated, “the assumption that I'm a woman, hence I must be a nurse is annoying because of old sexist ideas.” Jane stated when introduced as a resident doctor, patients often asked her (and not her male colleagues), “Are you studying to be a nurse?.” Emily remarked that being short (5′2″), diminutive, petite, and young-looking meant that she was not taken seriously. Patients' families often assumed her to be the nurse and addressed the male fellow first.
Both Caroline and Lucy shared that patients asked them to fill their water, asked for more pain medication, and treated them as a nurse or an aide. Lucy elaborated, “I can't [fetch water] ‘cause I gotta’ see another patient because I'm the freaking doctor.” A male attending told Barbara, “I don't think women should go into colorectal surgery. I don't think they're physically strong enough.”
Subtheme 4b: gender-based harassment
Many women physicians' interactions with patients or staff were gendered. They reported that they were treated differently than male physicians. They had to watch what they wore or said, pretend to be less forthcoming, and not correct their male peers if they said something wrong. Male colleagues talked over them in meetings. In addition, they reported that during surgical rounds, male attendings treated women trainees differently. During case discussions or when asked questions, Sarah recalled that “if a guy answered after you, he would still get credit for answering the question ‘cause he was louder, more obnoxious.”
Lucy described multiple harassment incidents during residency training, being forced to do substantially more clinical work than her male colleagues during her pregnancy. The chief resident had physically thrown the schedule at her out of frustration when she asked him to reschedule her shift duty that conflicted with her pregnancy check-up. When she was recommended complete bedrest, she was threatened that she would be fired for not doing her duties. “My doctor had to call them personally ‘cause they didn't believe I was going to the doctor.” She stated that she eventually developed preterm labor due to stress.
Connections between workplace violence and impostor phenomenon in medicine
The second research question examined connections between workplace violence and impostor phenomenon (Table 3). Participants felt like impostors when they were treated differently than men; made to question their competency or belonging; and when they saw fewer women physicians around them, or other women perpetrate violence.
Connections Between Workplace Violence and Impostor Phenomenon (Second Research Question)
Theme one: Different treatment for women and men
Despite long years of medical training (including residency), women were treated differently than men. Abigail shared, “Male colleagues were treated differently, greeted more warmly, and male patients were more receptive to diagnosis and medication prescribed by male physicians.” Women had to project confidence and constantly justify their role of physician. Barbara shared, “It wears away at your confidence.”
Patients often ignored women physicians, addressing, and asking questions to the tall, male medical student. Florence narrated, “We'll have patients complain that they haven't seen a doctor the entire time [even after she saw them], or when we enter the room they say on the phone, ‘Okay, I have to go. My nurse is here.’” In small community hospitals, women physicians used the nurses' lounge or locker room to change and scrub in for lack of a dedicated women's room. For dual-physician couples, the male spouse was always called a doctor by older male surgeons even when he was junior or had less experience. Women physicians found it harder to establish credibility and have others refer patients to them. In case of bad outcomes, women felt they were penalized more than men. Women who looked younger were treated differently and assumed to have less authority. Cara shared:
That makes me feel like I don't really belong here. The nurses challenge us more than they do the male physicians. Even the administrators will call us by our name. They'll introduce us without the doctor title, but they'll introduce our male colleagues as doctor, in the exact same meeting.
Theme two: Participants questioning competency and belonging
Nurses, patients, and patient families doubted women physicians, who, in turn, questioned their competency and described poor belongingness, especially after verbal attacks and demeaning comments from superiors about being incompetent. They struggled to get recognition. Colleagues were described as mean, sexist, and doubtful of women's competence. Elizabeth shared, “Hospitals can be a scary place if doctors, nurses, and your equals don't think of you as a doctor. That voice remains in your head.” Lucy narrated that while performing a specialized procedure of colonoscopy, a much older surgical attending intervened, saying, “Hey, you. Is this your first time doing this? Are you even trained to do this?” The attending never addressed her as doctor or asked her name. On saying that she had done this procedure many times before, he intervened and asked for an X-ray that he could not read despite his surgical training.
You're in the middle of somebody's rectum, operating, helping save them. And he is hollering shit at me, telling me that I don't know how to do it, and too young to do it. Yet, he can't read a general X-ray. I finished the procedure on my own.
Grace's current and early experiences of violence as a medical student continued to affect her.
Never once have I ever failed a test. Yet, the inner questioning comes from the constant microaggressions that we have to overcome just to get to medical school. I still keep showing up to take care of my patients, make sure we have a seat at the table, which oftentimes we don't.
Women often questioned themselves. Florence shared being “challenged by usually a male or seeing that someone is questioning my judgment against that of a male physician.” Even when making a wrong diagnosis, the confidence and authority with which a male resident (still in-training) spoke made everyone (including the patient) feel like he was in charge. Mary remembered an incidence when a male student “had the completely wrong plan in place, and it would have been deadly for this patient.” Yet, the student spoke with authority, and people trusted his diagnosis over hers, adding, “the gender factor in impostor syndrome is much more in females, but it is not just internal. It is also from these different sorts of external feedback we get.”
Patients and ancillary staff often expressed surprise when women physicians walked in. Abigail added feeling like being “a little bit more on the microscope because of my gender. I have to own not just my abilities but people's future opinions of all female surgeons' abilities.” This feeling eroded her confidence because “you're treated like you're not as smart or not as qualified just because of gender.”
Theme three: Women seeing fewer women physicians around and other women perpetrating violence
Many specialties were male-dominated with a “frat-bro culture.” Women had to work much harder to establish credibility and to be taken seriously. They heard sexist messages making them question their career choices. It was hard to find women mentors and sponsors. Women physicians with children obtained very little career support. Interestingly, sometimes other women showed little understanding or support. Nurses treated women physicians poorly. During Caroline's residency training, the nurse practitioners called male physicians a lot more for putting in IVs [intravenous] at the neonatal intensive care unit. “For me and other females, they would just do it themselves instead of calling us. So, I didn't get as much experience.” She added that while the nurses and physical therapists (all women) always called her by her first name, they called a male intern Dr. [last name].
When continuously harassed by a senior male doctor, Lucy tried filing a harassment complaint. Older women attendings defended him by calling it a personality issue (“That's just how he is”) and a language issue (“He is Chinese”). The assistant dean and the chief medical officer (both women) were completely unsupportive.
They blamed me, said everything was my fault, that I need to not be so sensitive and that I just needed to learn to deal. If that's who your boss's boss is, there's no long-term for you in that kind of program.
Discussion
The current study is possibly the first one that examined workplace violence and impostor phenomenon in medicine. Nineteen interviewees revealed experiencing physical, verbal, racial, and gendered violence (both gender-based assumption of position or competence and gender-based harassment). The connection between workplace violence and impostor phenomenon included different treatment for women and men; participants questioning competency and belonging; and women seeing fewer women physicians around and other women perpetrating violence. They experienced violence from people of all genders, including seniors and peers; men, and women physicians; mostly older, male patients; and women nurses.
The findings can be explained using Weiner's (1972) attribution theory whereby participants (95% women) attributed impostor experiences to an external factor (facing workplace violence) that they could not control every time (especially when harassed by a senior or someone in power of any gender). Experiencing violence made them question if they deserved their success at work and if they belonged in the field of medicine.
In medicine, women are well-represented at the student level (55.6% matriculants) (AAMC, 2022), but their numbers decline at the faculty (41.4%) and physician level (35.9%) (AAMC, 2019). Racial/ethnic minorities are underrepresented at all levels: as medical students, full-time faculty, and physicians (AAMC, 2018; Levant et al., 2020). The overrepresentation of male, white individuals, especially in higher ranks, could make others experience lack of belonging and impostor phenomenon. Those with marginalized identities lack critical mass, role models who share their background, and, as in this study, experience workplace violence. While violence and impostor phenomenon have been separately studied in medicine, the connections between them have not been explored before.
Workplace violence affects physical and psychological well-being among physicians. It impairs performance, causes burnout, impacts patient care quality, and maintains the gender gap by negatively impacting women's careers (Levant et al., 2020; NASEM, 2018). Contributors to workplace violence in this study included male-dominated, hierarchical environments; more men in positions of authority or power; reluctance to report violence for the fear of being ousted; and other women normalizing violence. Women medical students are mistaken as nurses based on gendered stereotypes, addressed patronizingly, hear sexually suggestive and sexist comments, and are inappropriately touched (Witte et al., 2006). Women physicians shared similar experiences in this study, including violence, poor belonging, and poor support from women colleagues. Interestingly, women also experienced violence through other women, both from peers and others in power. Participants describing both racial and gendered violence points to the intersection of identities along gender and race/ethnicity.
There has been a recent focus on developing interventions to manage or overcome impostor phenomenon (Chang et al., 2022). However, when impostor phenomenon is attributed to an external cause that is pervasive (e.g., experiencing violence), individual interventions will only have limited effectiveness without systemic, institutional changes such as better workplace sensitization, collective accountability, punishment when found guilty, and helping more women thrive in medicine.
Study limitations
Findings are not generalizable and based on a small sample. The sample is overrepresented by white women, whereas gender exists as a spectrum and racial/ethnic minorities may experience violence based on their numeric underrepresentation.
Conclusions
Interviews allowed a deeper exploration of violence and impostor phenomenon through in-depth narratives from 19 physicians. Impostor phenomenon could be activated through systemic inequities, especially for women (Mullangi and Jagsi, 2019). Future research should examine violence experienced by minorities due to race/ethnicity, sexual orientation, gender orientation, socioeconomic status, and generation status (Hill et al., 2020). As medical students transition to physicians, research should examine when one is more likely to experience impostor phenomenon (Chakraverty, 2024; Chakraverty et al., 2020; Chakraverty et al., 2018).
Footnotes
Acknowledgments
The author thanks all the study participants, the funding body at Washington State University, as well as Prof. Donna B. Jeffe (Washington University School of Medicine) for her mentorship, generous support, and constructive feedback.
Author Disclosure Statement
The author confirms that there are no competing financial interests.
Funding Information
This study was funded by the 2017 New Faculty Seed Grant (Washington State University) and Faculty Research Funding Award (College of Education, Washington State University).