Do I Belong Here? Confronting Imposter Syndrome at an Individual, Peer, and Institutional Level in Health Professionals

Introduction Imposter syndrome (IS) is a feeling of being an intellectual fraud and is common among health professionals, particularly those underrepresented in medicine. IS is accompanied by burnout, self-doubt, and beliefs of decreased success. This workshop aims to discuss the impact of IS and develop strategies to confront IS at the individual, peer, and institutional levels. Methods During the 75-minute interactive workshop, participants listened to didactics and engaged in individual reflection, small-group case discussion, and large-group instruction. Workshop participants and facilitators included medical students, residents, fellows, faculty, staff, and program leadership. Anonymous postworkshop evaluations exploring participants’ satisfaction and intentions to change their behavior were collected. Descriptive statistics were used to analyze the quantitative data, and content analysis was used to analyze participants’ intentions to change their behavior. Results The workshop was presented at three local academic conferences and accepted at one national conference. Data were collected from 92 participants. Ninety-two percent of participants felt the workshop met its objectives, and 90% felt the workshop was a valuable use of their time. Furthermore, 90% of participants stated they would apply information learned at the workshop in the future. The participants indicated an intent to change behavior on individual, peer, and institutional levels, while recognizing that barriers exist at all those levels. Discussion This workshop proved to be an effective means to discuss strategies on how to address IS at the individual, peer, and institutional levels. The materials can be adapted for relevance to various audiences.


Introduction
Imposter syndrome (IS) is the internalized feeling of self-doubt and not belonging in a particular group that can lead to the fear of being discovered as a fraud. It was first described in a population of high-achieving women by Clance and Imes in 1978. 1 Since then, this phenomenon has been increasingly recognized, with an estimated 70% of the general population having experienced IS at some point. 2 Importantly, IS is common within the medical profession. It is known to impact all levels of medical training, beginning with medical students 3 and continuing during stages of transition 4 and even in senior faculty. 5 Additionally, studies have explored how self-identifying with an underrepresented group in medicine, including racial, ethnic, gender, LGBTQ, religious, and other minorities, contributes to IS. 3,[6][7][8][9] Furthermore, IS fosters self-doubt and impacts ability to receive feedback, resiliency, well-being, and success. At the systemic level, those who experience IS may be less likely to apply for promotions for fear of failure, leading to decreased diversity in leadership positions, such as deans or department chairs within academic medicine. 10 To effectively promote diversity, equity, and inclusion within academic medicine, IS must be recognized, acknowledged, and confronted on both individual and systemic levels to strengthen the pipeline of diverse candidates.
Effective tools and strategies to identify and confront IS are very limited; however, some interventions have been implemented within the health care professions. A facilitator-guided 30-to 45-minute intervention on 21 internal medicine residents was published in MedEdPORTAL. 11 This intervention included selfreflection, think-pair-share, and large-group discussion; 81% of the participating residents felt the intervention promoted resident wellness. A 3-hour educational session with new medical interns involved small groups, role-playing, and facilitator feedback. 12 It was well received by the trainees and helped them realize that they could ask others for help and were not alone in their feeling of fear. A 1-day interprofessional educational workshop where participants took the Clance Impostor Phenomenon Scale (CIPS), listened to didactics, and engaged in discussion helped clinical nurse specialist students feel a sense of liberation and empowerment. 13 An online module consisting of a 14minute educational video with supplemental reminder cards of proposed coping mechanisms was presented to a cohort of dental students. 14 Based on pre-and postmodule CIPS responses, there was a decrease in IS scores at the end of the semester. These interventions show the strength of modules and workshops in improving awareness of IS and providing strategies that help reduce the impact of IS in health care professionals.
While studies have provided evidence that interventions to address IS are effective in reducing feelings of IS, clear tools and strategies that focus on IS and diversity are lacking. This module provides an interprofessional framework for medical trainees, faculty, staff, and program leadership to understand, acknowledge, and confront IS while promoting diversity, equity, and inclusion through interactive didactics, group sessions, and strategies directed at IS that may change behavior.

Workshop
The workshop was developed using Kern's six-steps of curriculum development 15  r Develop tools to address IS at the individual, peer, and institutional levels. 4. Educational strategies: In order to engage the audience, a mixture of direct and interactive learning was used.
Interactive methods included using word clouds, smallgroup discussion, and large-group discussion. 5. Implementation: The formal workshop comprised didactics, individual reflection, small-group case discussion, and large-group instruction that correlated with Bloom's taxonomy. 16 6. Evaluating the effectiveness of the curriculum: Immediately after the workshop, participants completed an evaluation assessing its effectiveness in meeting objectives.
The workshop was aimed at participants of all levels, including students, residents, fellows, faculty, staff, and program leadership. It was designed as a 75-minute session; however, the timing could be amended to meet the specific needs of the audience. The workshop could be incorporated during orientations, retreats, and diversity, equity, and inclusion conferences; across all health care professions; and at various institutions, including academic and community hospitals and clinics.
Workshop facilitators could be residents, fellows, faculty, staff, and program leadership. In a 60-minute training session, facilitators were taught about the IS phenomenon, definition, evidence-based research, and potential strategies to assist with feelings of IS. Facilitators' roles were assigned beforehand and included sharing personal narratives, leading didactics, facilitating small-group discussions, guiding large-group instruction, and assisting with logistics during the workshop (Appendix A).
Small-group sizes were ideally six to eight participants. As they entered the room, participants were divided into small groupseither randomized groups or separated by professional role (i.e., student-only group, resident-only group, staff-only group, faculty-only group). The layout of the room, the number of participants, and the different learner levels were factors that assisted in determining which small-group format was ideal to meet the workshop needs. Randomized groups composed of individuals with different levels of training and expertise provided diverse perspectives when discussing the small-group cases, whereas groups divided by professional designation fostered an environment of comradery and vulnerability given that other individuals might be experiencing the same issues discussed at the very same time.
As the workshop started, the facilitators shared their personal experiences of IS, which created an environment where vulnerability was respected and invited. The facilitators then discussed the learning objectives of the workshop.
Participants were asked to reflect on their own thoughts and experiences concerning IS by participating in an interactive word cloud and completing a validated IS quiz (Appendix B). The word cloud was created via Menti.com and asked participants, "What is imposter syndrome? If you don't know, you may answer 'IDK'." If unable to create a word cloud through Menti.com, an alternative would be to have participants raise their hands to answer the question while the facilitator writes their responses on a board. The validated IS quiz was the Young Impostor Scale (YIS), an abbreviated eight-question quiz using yes-or-no statements. 3 Responding yes to five or more of these questions was considered a positive finding of IS, which provided realtime individualized and private feedback to the participants. The participants were asked to discuss their perspectives and reflections on both activities. Facilitators then led a short didactic on IS, which included an optional showing of a 2-minute TED Talk video excerpt on IS 17 and shared evidence-based research on the effects of IS in medical students, residents, and attendings.
Following this introduction to IS and participants' reflection on its impact on their own lives, the workshop continued with interactive discussion of cases in facilitated small groups, followed by large-group discussions. Small-group cases were developed based on personal experiences of the authors and their colleagues and were created to reflect experiences with which the participants could identify. Depending on the number of small groups and how they were divided, each group was assigned one to two cases (Appendix B). Once participants had read their assigned cases and the first two discussion questions to themselves, each small group discussed the cases together. Then, small groups shared their reflections with the entire group, with one facilitator leading the discussion and another facilitator assisting with the audience responses.
For the last discussion question, small groups reconvened and developed strategies to overcome IS on the individual, peer, and institution levels. Facilitators led this large-group instruction, combining the strategies the small groups had suggested with evidence-based and expert consensusdriven strategies developed for the workshop (Appendix B). Afterward, postworkshop evaluations were collected from all participants.
The workshop time line (with materials) was as follows: r Preworkshop preparation: • One hour of facilitator training; materials: facilitator guide

Analysis
Descriptive statistics were used to analyze the quantitative data (percentage of participants who strongly agreed or agreed). Content analysis was used to analyze the participants' intentions to change their behavior, with two investigators (Nancy Rivera and Elana A. Feldman) reviewing the data independently and then comparing line by line until consensus was achieved. A third investigator (Rebecca Blankenburg) helped reconcile any conflicts. Frequency counts were determined by the number of times a theme was mentioned by any of the participants.

Institutional Review Board
The postworkshop evaluation form was reviewed by the Institutional Review Board of Stanford University (Protocol Number 45076) and was determined not to qualify as human subjects research.

Results
This workshop was facilitated by eight presenters: two residents, one fellow, one staff member, and four faculty members. It was presented at three local academic conferences (2019 Stanford Diversity and Inclusion Forum, 2019 Stanford Medicine Radiology Diversity Fair, and 2019 Leadership Education in Advancing Diversity Seminar). The workshop was also accepted at one national conference, the Pediatric Academic Societies annual meeting; however, due to COVID-19 restrictions, it was not presented. There was a total of 92 participants, comprising residents, fellows, staff, faculty members, and program and department leadership.
Ninety-two percent of participants felt the workshop met its learning objectives, while 90% of participants felt the workshop was a valuable use of their time. Furthermore, 89% of participants felt the supplemental handouts were useful, and 90% of participants said they would apply information learned at the workshop in the future (Table 1).
Participants were asked to indicate two things that they would do as a result of the workshop. Strategies emerged on individual, peer, and institutional levels ( Table 2). On an individual level, seeking mentorship (15% of responses), practicing selfcompassion (21% of responses), allowing for vulnerability (15% of responses), and having physical reminders of personal accomplishments (13% of responses) were frequent strategies that emerged as a result of the workshop. On a peer level, the majority of participants indicated they would attempt to celebrate the successes of their peers (22% of responses) and to alert others to their own IS (23% of responses). On an institutional level, participants wanted to increase institutional education on IS (29% of responses).
Participants were asked to indicate barriers to implementing what they had learned from the workshop. Themes emerged on individual, peer, and institutional levels ( Table 2). Barriers on an individual level included ingrained thought processes (11% of responses) and self-doubt (16% of responses). On a peer level, lack of support (22% of responses) and lack of openness with others (11% of responses) were identified as barriers. Lastly, institutional barriers included difficulty to change the culture within departments (22% of responses) as well as daily workload pressures (13% of responses).
Of the various workshop components, the small-group discussions were the most preferred among the participants.

Discussion
We developed and implemented a workshop to provide a framework for health care professionals to understand, acknowledge, and confront IS in the health care workforce. The workshop was well received by participants, and their feedback indicated that this is an important area that is not discussed or taught regularly. In presenting this workshop, we learned several lessons. The most important lesson was that familiarity with the concept of IS and experiences of IS varied widely. Some groups wanted an introduction to the concept of IS, while other groups wanted to explore mitigating the effects of IS more deeply. Because the most helpful part of the workshop for many people was small-group discussion of strategies to mitigate IS, the workshop has been designed to incorporate flexibility and group participation.
We encountered a few barriers when running the workshop. The first was how to successfully lead an interprofessional group through a joint workshop. We initially focused on separating groups by professional role/training level and using scenarios that specifically applied to each group so that the groups could teach each other about their own experiences of IS. However, we found that participants much preferred to be in randomized groups and appreciated more generalized scenarios. Participants preferred discussing IS in randomized groups as this would help impact change across departments and the institution on a greater level. We also found that some groups that initially had no experience with IS were more reluctant to engage at first. This situation was improved by an initial didactic session and techniques like the word cloud, which allowed anonymous responses.
This workshop has been designed to be generalizable to many settings; however, it requires flexibility depending on a group's previous knowledge of the subject. The multiple scenarios allow workshop facilitators to pick what is most relevant for their group. The modalities (PowerPoint slides, cases, small-group discussion, and large-group discussion) have been designed to be easy to implement in many settings.

Limitations
Our workshop has several limitations. Participants might have been affected by social desirability bias, although we attempted to reduce this by using anonymous evaluations. Without demographic information, we cannot determine who would benefit from the workshop. Future studies can include a survey collecting demographic information separate from the workshop evaluation. We measured participants' intended behavior change, and future studies should explore their actual behavior change.

Conclusions
We successfully developed a workshop to help health care trainees, faculty, staff, and other members of the health care workforce discuss a framework for understanding IS as well as mitigating IS in their own professional contexts. The workshop empowers participants to recognize IS in themselves, their coworkers, and their mentees and can help foster a culture of support in professional advancement. As IS most affects those who have been historically underrepresented in medicine, this workshop and others like it can influence advancement at all levels.