“Dr A…I don’t know…I feel like everyone else has the answers and knows exactly what they are doing. I’m afraid to speak up during rounds. I sometimes feel like I don’t belong here.”

—First Year PCCM Fellow

If people don’t feel safe, they’re not going to have hope.

–Lori Lightfoot

 

I have been teaching, and serving as a confidential and informal “coach,” for fellows and residents from a wide-variety of specialties/ subspecialties for 25 years. In this unique role, I have had the great privilege of hearing about the challenges and struggles inherent in graduate medical training from hundreds of brilliant, compassionate, and accomplished young physicians. It has never ceased to surprise me that many of these outstanding learners tend to view themselves as unworthy of their accomplishments and, in fact, tend to feel “less than” their peers.

Psychology Today defines “imposter syndrome” as a phenomenon that occurs in high-achieving individuals who “believe that they are undeserving of their achievements and the high esteem in which they are, in fact, generally held. They feel that they aren’t as competent or intelligent as others might think—and that soon enough, people will discover the truth about them. Those with imposter syndrome—which is not an official diagnosis—are often well accomplished; they may hold high office or have numerous academic degrees.”

Up to 30% of high-achievers suffer from this “impostorism,” and approximately 70% of adults may experience imposter syndrome at least once in their lifetime. And, it could be argued, that even if a learner doesn’t meet full criteria for this syndrome, many physicians in training (especially first-year fellows who are not yet familiar with the systems in place at their new institution) experience bouts of self-doubt and anxiety. Indeed, anxiety in young doctors is a common occurrence (“the smarter you are, the more you think. The more you think, the worse you feel—this is why they say, ‘ignorance is bliss’! —Dr A).

 

“The strength of the team is each member. The strength of each member is the team.”

–Phil Jackson

When individuals feel like imposters and/or are experiencing anxiety and self-doubt, they are not performing at their optimum level. To provide the best care to patients, teams in the intensive care unit must communicate effectively and seamlessly, be cohesive and must give each individual member the opportunity to shine and perform at their highest level. Each team member must feel valued. Each team member must feel that their voice is heard and respected and appreciated.

So, considering what we know about the high percentage of imposter syndrome and anxiety in our young physicians, how can we best create a culture of safety in our teams? One of the most important ways to do this may be to focus on building a sense of “belonging” and this can be accomplished through the attentiveness and kindness of the team leader.

 

Kindness and faithfulness keep a king safe, through kindness his throne is made secure.

–King Solomon

The Agency for Healthcare Research and Quality (AHRQ) suggests that team leaders and members can promote psychological safety by:

  • Inviting input from all team members.
  • Encouraging team members to contribute.
  • Promoting active listening and learning from each other.
  • Celebrating failures, providing positive reinforcement for innovations even though they don’t always work.
  • Acknowledging the limits of their own knowledge.

 

The latter point above is especially salient for those learners who are struggling with imposter syndrome. Dr Pamela Wible has proposed the notion of being” a warm line” for others. In essence, this is the idea that when attendings/seniors/team leaders share their own vulnerability/imperfections, this act will allow others to feel more comfortable. For example, a team leader who states, “I remember when I was a fellow—I felt like everyone knew more than

I did and I was terrified of making a mistake” can create a sense of safety for juniors through normalization of these very common feelings. They recognize they are not alone through this powerful realization that even their role-models have struggled with the same feelings. One of the very best things we can do for our learners, in my opinion, is to help them realize they are not alone.

Since those team members who may be doubting themselves might not speak up in a large group, according to AHRQ, team leaders can foster psychological safety one-on-one by saying things like:

  •  “I’m not sure we’re following the protocol correctly. Let’s check.”
  •  “That’s a great point. I think the whole team needs to hear that. Can you bring it upon rounds tomorrow morning?”
  •  “As long as I’m not with a patient, feel free to grab me anytime. Remember, there’s no such thing as a stupid question.”

 

Other effective ways for team leaders to promote kindness, inclusion and safety on their teams is through simple phrases, such as:

“Everyone on this team is an extremely valued member. I want you each to feel comfortable reaching out to me individually, as well as in this larger group, with any ideas, concerns, suggestions. You each bring unique strengths to our team and you each belong here.”

“If you see anything amiss—please speak up. No one is perfect and even me, as your team leader, makes mistakes.”

“If you have a different view or opinion—that’s great! Please feel free to speak up—in the larger group or one-on-one with me. Your opinion is greatly valued.”

In addition, when a new team is assembled, a bonding or ”ice-breaking” (i.e., anxiety-reduction) exercise which the leader may consider might be to have each member introduce themselves, share a bit about where they are from, what they feel they bring to the team and a personal aside (“what are your favorite things to do outside of medicine” and “if you weren’t a doctor, what would have been your dream career?”). Furthermore, meeting with each team member one-on-one and asking about their goals/expectations for the rotation/team and how you, as a team leader can help them achieve those important goals/expectations, may also foster a sense of inclusion.

In summary, kindness, empathy, attentiveness to each member by the team leader can not only create safety; it can also enhance performance of the entire team by fostering a deep sense of inclusion and self-worth for each member—which will enable everyone to feel that they truly DO belong here.

 

Heidi Allespach, PhD is a Professor in the Departments of Medical Education, Medicine and Surgery at the University of Miami Miller School of Medicine/Jackson Memorial Hospital. In her unique role in multiple programs, she has served as an informal, confidential resource for hundreds of outstanding residents and fellows for over 25 years.