YOU ARE NOT AN IMPOSTER. YOU’RE A HUMAN. Joan Naidorf, DO

Joan Naidorf, DO, is an emergency physician, author and speaker based in Alexandria, VA. Her book, Changing How

Patients, (American Association for Physician Leadership) was published in 2022. She blogs at https://www.drjoannaidorf. com/ and at Joan Naidorf – Medium.

By Joan Naidorf, DO

It feels like everyone is talking about imposter syndrome. Imposter syndrome is defined as doubting one’s abilities or feeling inadequate, like a fraud. It disproportionately affects high achievers and perfectionists who tend to find fault even with their own marvelous accomplishments. Every human feels it from time to time, even men. Much of the writing and studies seen recently in the media focus on the phenomenon in women and speaking of it in terms of a medical or psychiatric diagnosis.

The Harvard Business Review has gotten in on the movement. Authors Ruchika Tulshyan and Jodi-Ann Burey ask the people in the business world to “Stop Telling Women they have Imposter Syndrome.” They object to taking a “fairly universal feeling of discomfort, second-guessing, and mild anxiety in the workplace and pathologized it, especially for women. The authors resent the victim blaming of a biased system that makes women feel as though they do not belong. They write, “For women of color, universal feelings of doubt become magnified by chronic battles with systemic bias and racism.”

In Emergency Medicine News, Dr. Simons (AKA the ER Goddess), wrote a response to the Harvard Business Review authors and the general public regarding her take on the matter. In “It’s Not Imposter Syndrome—It’s Gender Bias” she frames the issue in medical workplace and training programs. She writes, “The discomfort that women have been convinced is imposter syndrome is not a psychological affliction but a normal response to being female in a culture rife with gender discrimination.”

She concludes, “Labeling female physicians as having imposter syndrome may be easier than changing workplace culture, but it inappropriately blames individuals for natural reactions to persistent sexist overtones in medicine. Rather than helping women fight imposter syndrome, we should be fighting gender discrimination.”

In the blog section of Women in White Coats, Dr. Mary McCrary, wrote of her own experience with imposter syndrome as she rose through the ranks of medical student, intern, OB resident and then OB chief resident. She noted at every stage of transition, the professionals around her were at a higher level of experience and training and by comparison, she naturally felt inadequate. By the time she reached her chief resident year, she realized

her own thoughts about her skills and what she had to offer to patients and trainees had to change. She wrote, “I knew how to be more aware of my thoughts; I learned how to adjust those thoughts, and ultimately I knew how to have a different opinion of myself. I was able to see these limiting thoughts and reframe them.”

In the Doximity Op-Med section, Dr. Kristin Yates related her own feelings of imposter syndrome as she also rose through the ranks as an OB-GYN resident. She found that the thoughts of inadequacy followed her even as she became more experienced and successfully advanced in her medical training. Dr. Yates finally realized, “What I know now is that we must deal with impostor syndrome head on if we want to overcome it. Dealing with it head on means recognizing it for what it is: a normal part of being a human being, especially if you are a “high achiever.” Unfortunately, it does not resolve on its own with time and experience. Our brains will think of new excuses about why we don’t belong. That is, of course, unless we teach ourselves how to recognize the thoughts that cause impostor syndrome and provide new thoughts instead.”

I have the utmost respect for my colleagues, and I appreciate the experiences and opinions they have shared online. I agree and disagree with their positions. The imposter syndrome is not an actual disease or affliction that strikes women in our profession. There is no listing in the Diagnostic and Statistical Manual of Mental Disorders. We do not require medication or treatment. We are not to blame for the condition, nor should we labor in shame.

Yes, there is both racial and gender bias within our society, our medical training system and our workplaces. Yes, we all should be fighting against racial and gender bias within hospitals and offices. Even if we waved a magic wand and all racial and gender bias in the workplace instantaneously went away, women would still question their adequacy because all their current experiences are filtered through their own brains.

No one can force us to feel inadequate. Inadequacy is a feeling caused by a thought like, “maybe I’m not good enough” or “maybe I don’t really belong here.” We get to choose for ourselves what we think in every situation. Like it or not, those of us raised as persons of color and women in our society have internalized the thoughts of bias that were offered to us on television, movies and the classroom. We need to choose better thoughts. Additionally, we judge ourselves harshly. While we wait for the world and society to fix biases, we have to work on our own thoughts first and exercise self-compassion.

The imposter syndrome is just a description of a collection of your own critical, self-talk thoughts. That’s it. Some high functioning, perfectionistic people, particularly some women, never feel good enough. They always feel like there is something wrong with them or they need to fix the next thing or get the next fellowship to finally feel okay about themselves. This brutal self-criticism and judgement has got to stop. We need for every person to love themselves first and believe in their own worthiness. Every person needs to bring their best selves to the clinical bedside, the operating room or the meeting. We need to change from within and the way to do that is to change what we think about ourselves first. This is what we can do today, while we wait for society to change.

Did you know that you can change your thoughts just by practicing thinking something new, on purpose, that you can believe? You have to repeat the desired new thoughts many times for them to stick. It takes practice to undo a lifetime of habitual self-criticism and internalized bias. When society or your own brain offers you an old-fashioned and un-helpful thought about your own abilities or worthiness, you just need to politely decline that notion. In the human experience, moments of self-doubt will inevitably pop-up and cause us to question ourselves. This is normal. You need to think, “I belong here. I can do this and in fact, I can do this well. I’m amazing. I’m a badass.” You can think this even when you don’t know the answers to questions on rounds or when you make a mistake (and sooner or later we all will.) This is all part of the human physician experience. Thank you for putting on your scrubs or your white coat to take care of us. We need every one of you to put your best self out there with confidence. –•–

Introduction

As a first-year medical student wearing your new white coat, you embark on your first community experience—a home visit with your geriatric mentor at their house along with a first-year colleague. Over coffee and scones, just as you’re getting to know your mentor while gathering their history, they start complaining of chest pain. Knowing their extensive cardiac history, you immediately go to call 911 and notice they are unresponsive. You contemplate what you, as a first-year medical student, are expected and able to do.

There are more than 350,000 out-of-hospital cardiac arrests each year.1 During medical school, students are taught Basic Life Support (BLS), but schools provide the training at different times over the four years. Several osteopathic medical schools provide formal BLS education during the first year or even orientation. At some schools, students take an emergency medical technician class at the beginning of first year. Though BLS certification is provided just prior to clerkship years at the University of New England College of Osteopathic Medicine (UNE COM), a group of medical students at UNE COM believed that BLS is an important set of skills that should be gained earlier in medical school education. Preclerkship years at UNE COM include several clinical experiences that involve visiting older adult mentors in their home. UNE COM medical students have encountered sudden cardiac arrests in the local community. Seeing all of this, that group of medical students within the EM Club at UNE COM, a chapter of the ACOEP RSO, took it upon themselves to host a BLS course. The unique course, drawing from the previous experience and education of EM Club members, was designed and delivered almost entirely by first- and second-year medical students. Offered twice before the COVID-19 pandemic altered course delivery in medical school, over forty medical students were certified in BLS.

Setting Expectations

Throughout medical education, students are learning alongside clinicians, both dressed in white coats. This most often occurs during clerkships but does occur in preclerkship years when students have minimal clinical training or experience. It may be difficult for the layperson to distinguish between an experienced clinician and a student. With the white coat comes the price of public perception, even as a first-year student—one that sets expectations for a level of competency, knowledge, and trustworthiness.2 In fact, patient perception of knowledge was highest for physicians who sport the white coat either formally or with scrubs.3 This expectation is not reserved for physicians in white coats but is often assumed for all in white coats, thus including medical students. Though the adults involved in UNE COM’s geriatric programs are aware of students’ status as pre-clerkship learners, most are unaware of medical education curricula and student proficiencies. The gap between expectation and knowledge could be the difference in a medical student initiating BLS in the case of an emergency.

In addition to the pre-clerkship concerns, there is an expectation that students receive sufficient training in BLS and Advanced Cardiovascular Life Support (ACLS) when they move to the next phase of medical education. In fact, 68.9% of residency program directors feel it is important to have BLS skills assessed in the first year of residency, and 90.1% of surveyed directors believe it should be assessed during training at some point.4 The Association of American Medical Colleges (AAMC) requires competency at providing early management of patients in critical condition with basic and advanced life support as requirements for

graduation from medical school.5 Admittedly, there is poor retention of CPR and BLS knowledge. The American Heart Association reports that it may be “reasonable for BLS retraining to be completed more often by individuals who are likely to encounter cardiac arrest.”6 Similarly, there is evidence that medical students with prior BLS training have improved performance in repeat simulations.5 The ability to increase training opportunities with more courses earlier on, supports the improvement in the quality of BLS and ACLS care provided.7 By providing a BLS course early in medical education, there is time for repeated courses and increased knowledge recollection, which hopefully allows increased competency among students in pre-clerkship preceptorships, clinical experiences, and beyond. Developing a Curriculum

Seeing a need for a BLS course earlier in medical school, students in the EM Club at UNE COM designed and taught a course targeted to medical students. The goal of the unique curriculum is to combine standard BLS curriculum with information pertinent to the physician’s role in cardiac arrest management. The course is still the four-hour standard and includes CPR, rescue breathing, and treatment of foreign body obstruction. One distinct advantage of targeting the course toward medical students is their in-depth understanding of anatomy and physiology. Their knowledge base is greater than the general public or those targeted by standard BLS courses, which allows this curriculum to draw parallels that others might not be able to, including cardiovascular physiology during CPR or human anatomy as it relates to airway maneuvers. Additionally, the curriculum includes a specific session, led by an emergency physician, that explores the physician’s role in cardiac arrest management. The intent of this session is to highlight the leadership, time management and overall mindset needed by a physician while running a code.

Perhaps the most powerful aspect of the curriculum is that it is primarily delivered by medical students. Many medical students come into medical school with prior educational experience or instructor certification, and the EM Club took advantage of this to ensure proper instruction from organizations like the American Heart Association and the American Safety & Health Institute. Providing a student-led curriculum not only helps medical students gain experience teaching—which is not an oftprovided opportunity in medical school—but allows a unique connection between students. Steven Ferro, a 2021 UNE COM graduate, said the student-led BLS course gave him the “ability to connect with people you know and are in the same boat, rather than an instructor not used to medical students.” It is essential for educators to understand the context in which the learners likely need to draw upon the things they have learned. In this situation, perhaps no one understands medical students better than the students themselves.

Why It Matters

BLS education for medical students is not well retained, no matter when it is introduced in medical school. Knowledge of BLS is generally low among medical students despite an expectation that medical students should know how to manage a cardiac arrest.8 Medical students are generally well prepared to understand the pathophysiology behind cardiac arrest but may not actually know how to properly intervene and manage an out-of-hospital cardiac arrest.9 A targeted approach to teaching BLS, such as this student-led curriculum, could be a way to address this larger problem. By providing an early introduction to the basics, there is more opportunity to build and refine skills throughout medical school. In fact, more than 75 percent of the participants in this BLS course at UNE COM had expected to receive CPR training at some point before or during their first year of medical school. An early BLS course also builds confidence early in medical school with a new skill set.

Conclusion

While the COVID-19 pandemic has dramatically changed medical education and has prevented the EM Club from offering the student-led BLS course the last two years, there remains a need to continue finding ways to provide medical students with essential skills throughout their years of medical school. Certainly, further research would be needed to determine if targeted BLS courses earlier in medical school with involvement from medical students offer advantages regarding retention and effectiveness. Still, it’s important for students and educators to be creative to expand and evolve the ways medical education is delivered.

References

1. Benjamin EJ, Virani SS, Callaway CW, et al. Heart Disease and Stroke Statistics-2018 Update: A Report From the American Heart

Association [published correction appears in Circulation. 2018 Mar 20;137(12 ):e493]. Circulation. 2018; 137(12):e67-e492. doi:10.1161/

CIR.0000000000000558 2. Chung H, Lee H, Chang DS, et al. Doctor’s attire influences perceived empathy in the patient-doctor relationship. Patient Educ Couns. 2012; 89(3):387–391. doi:10.1016/j.pec.2012.02.017 3. Petrilli CM, Saint S, Jennings JJ, et al. Understanding patient preference for physician attire: a cross-sectional observational study of 10 academic medical centres in the USA. BMJ Open. 2018; 8(5):e021239. Published 2018 May 29. doi:10.1136/bmjopen-2017-021239 4. Langenau EE, Zhang X, Roberts WL, DeChamplain AF, Boulet JR. Clinical skills assessment of procedural and advanced communication skills: performance expectations of residency program directors. Med Educ Online. 2012; 17:10.3402/meo.v17i0.18812. doi:10.3402/meo. v17i0.18812 5. Gupta R, DeSandro S, Doherty NA, Gardner AK, Pillow MT. Medical and Physician Assistant Student Competence in Basic Life Support:

Opportunities to Improve Cardiopulmonary Resuscitation Training. West J Emerg Med. 2020; 22(1):101–107. Published 2020 Dec 15. doi:10.5811/westjem.2020.11.48536 6. Bhanji F, Donoghue AJ, Wolff MS, et al. Part 14: Education: 2015 American Heart Association Guidelines Update for Cardiopulmonary

Resuscitation and Emergency Cardiovascular Care. Circulation. 2015; 132(18 Suppl 2):S561–S573. doi:10.1161/CIR.0000000000000268 7. Lund-Kordahl I, Mathiassen M, Melau J, Olasveengen TM, Sunde K, Fredriksen K. Relationship between level of CPR training, selfreported skills, and actual manikin test performance-an observational study. Int J Emerg Med. 2019; 12(1):2. Published 2019 Jan 10. doi:10.1186/s12245-018-0220-9 8. Willmore RD, Veljanoski D, Ozdes F, et al. Do medical students studying in the United Kingdom have an adequate factual knowledge of basic life support? World J Emerg Med. 2019; 10(2):75-80. doi:10.5847/wjem.j.1920-8642.2019.02.002 9. Baldi E, Contri E, Bailoni A, et al. Final-year medical students’ knowledge of cardiac arrest and CPR: We must do more! Int J Cardiol. 2019; 296:76–80. doi:10.1016/j.ijcard.2019.07.016

Justin D. Doroshenko, DO, M.Ed., Paramedic, FAWM Justin is a physician, paramedic, and educator based in Asheville, NC. A graduate of the University of New England College of Osteopathic Medicine, he currently serves as the Director of Education for Hawk Ventures and faculty for NOLS Wilderness Medicine.

Kaitlyn DeStefano, MS-4 Kaitlyn is a fourth-year medical student and EM residency applicant from the University of New England College of Osteopathic Medicine. Originally from Farmingdale, NY, Kaitlyn is a former EMT, medical scribe and Division II Volleyball All American.

AJ Halstein, MS-4, EMT AJ is a fourth-year student at the University of New England College of Osteopathic Medicine and EM residency candidate. In his previous career, he was an EMT and a CPR instructor with the American Heart Association. Beyond medical school, his goal is to continue teaching others in the medical community.