Imposter Syndrome, Duning-Kruger Effect, and Attending Land Mines

Please don’t ask me.  Please don’t ask me.  Oh, God, the attending is going to ask me the answer.  I probably don’t know it.  What if they find out that I don’t know anything at all?  This is the point I get kicked out of medical school.  Maybe I am going to be the worst resident ever.  How could I ever be an attending physician?  They all seem so confident in what they do.  I could never be that way….

Have you ever felt that impending doom while on rounds?  If you have any humility about yourself, the answer is probably yes.  It’s called “imposter syndrome.”  The prescription?  Avoid the Duning-Kruger effect. Want to know what that is and how to avoid it?  Just keep reading.

We are all faking it til we make it

Someone told me in medical school that there was a trick to being an attending physician.  [Being an attending now, I’ve found it to be true.]  See, each attending has a breadth of knowledge that is (the vast majority of the time) adequate to take care of patients.  The trick is that each attending really has 8 or 10 topics where they have a ton of depth.  So, while you are on rounds they let you talk until you broach one of those subjects.

At that point, that is when they go to town:
Attending: “Doctor Smith, what are some possible causes for this patient’s non-gap acidosis?”
Resident: Uhhh…….  hypoventilation?
Attending: “Anything else, doctor smith?”……  “Well, let’s discuss aldosterone and it’s impact on the acid base homeostasis in the body.”

Little did you know that this is the area of research for that attending and where they have spent the majority of their time in study.

Unfortunately, when you are the one being asked the question, you assume that the attending physician has you pegged.  They’ve finally figured it out.  They know everything, and you know nothing. You’re feel like an idiot, and you don’t know the answer.  In reality, you’ve just hit one of the ten attending land mines.  This is also known as the “attending physician knowledge bomb.”

Just remember:  This, too, shall pass.

This doesn’t change

As a brand new attending (if you are a reasonable person) the feeling that you know nothing doesn’t change.  In fact, the good attending physicians realize that they need help and often ask for second opinions or advice from elder statesmen/women.  I commonly run a case by an older attending to get their opinion.  The key is to make your decision first and see if they agree.  You don’t want to be trigger-shy.

Those that fail to realize that they lack experience suffer from something called the Dunning-Kruger effect. You know what that is, don’t you?  It can be summed up (and often is) by the following fantastic graph:

Duning Kruger

As a new attending physician (or resident physician), what you really want to avoid is “mount stupid.”  This is easily done by recognizing that you don’t have the experience, and that as you gain experience your confidence plummets.

Always ask questions, thank those that teach you, and learn from each mistake.  It’s as simple as that.

Imposter Syndrome

I would add an arrow to the graph above at the bottom of the valley.  This would be called “Imposter syndrome.” This is the point where you actually have a decent amount of experience, but your confidence is terrible.  At this point, you think you are an idiot, but its actually because you’ve seen enough to know you don’t know everything.  Imposter syndrome is made of several helpings of humble pie.

The solution for this, of course, is to “fake it til you make it.”  In fact, your faking it probably isn’t even faking it anymore at this point.  You just feel like you are faking it.  Trust yourself.  Trust your training.

Take Home

The point of this post is to point tell the students and residents in training that these feelings are normal.  It’s okay.  In fact, it probably means you are on the right track.

Don’t feel defeated when others around you seem confident.  They are just further along in the journey and a little better at “Faking it til they make it.”

At some point, your knowledge and experience will match and you will be an expert.  Until that point, realize that it is okay to ask for some help, and feeling like an imposter is normal.

Have you ever felt like an imposter?  Do any of you feel like you are just waiting for someone to figure you out?  Are you furhter along in your career (And, if so, what words of advice do you have for the young trainee or freshly minted attending?).  Leave a comment.

TPP

8 thoughts on “Imposter Syndrome, Duning-Kruger Effect, and Attending Land Mines

  1. There’s nothing hat pisses off the expert more then the person on mount stupid. Avoid that spot like the plague. For all else realize no one knows everything. Even the expert gets stumped from time to time. So don’t be afraid to ask for help.

    Not a physician but see this in my work place as well.

    • Yeah, this isn’t unique to doctors at all. We all know those overconfident people who don’t have perspective. Mount stupid is not the place to be!

      Asking for help is always key. Recognizing your weaknesses will only make you stronger.

  2. Medical school and residency is about getting molded and if you let yourself get molded it can be a lot of fun. When I quizzed “students” I could give 2 ***** about what they know, just about what I could teach them. It’s all down hill from mt stupid. I remember as a third year DR CARDIOLOGIST had me listen and asked me what I heard. I told him an “evanescent right sided third heart sound”: he totally cracked up. All i knew was this guys RV was sometimes clickin after dub.

    Why do you think we attendings call consults 🙂

    • That last piece is gold. Great way to think about the fact that we all need help. As an acute pain anesthesia doc 100% of my work is consultant work. Just goes to show someone needs help, because…we all need help.

      And I agree about the knowledge gaps for students. I don’t care what you don’t know… I am just trying to find it so I can teach you.

  3. I like that term ” attending physician knowledge bomb”. I med school, I had a neurology attending who diagnosed everything as a form of seizure. He didn’t have much credibility.

    • Oh, for sure in blogging. I am still trying to find my voice it seems. That apparently takes a while.

      All I know is I want to help those coming behind me not make the same mistakes I did and to figure it out a little sooner!

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