Imposter, MD

5 years ago

Last week I began functioning as a real doctor.  I didn’t wear a long white coat because family medicine doctors are too counter-culture to wear white coats but, I did write a prescription without having to run around looking for a doctor's signature.  I filled out official medical paperwork and signed "MD" behind my name. When my patient addressed me as, “doctor” instead of babbling out the usual, “No, no. I’m a medical student, but perhaps I can still be of help. If not, I’m certain I can find someone who can,” I simply turned and said, “Yes?”

As excited as I am to be moving forward in my training, and as sure as I am that I learned many useful things over the past four years of medical school, I can't shake the feeling that when I say I'm a doctor, people have an image of what that means that is different from what I actually am.  As my co-intern said the other night at happy hour, "Is anybody else suffering from intense imposter syndrome?" Unanimous nods.

Acknowledging it out loud helped explain the thoughts that had been popping into my head the past few weeks.  Whenever I had a moment of downtime, memories that I hadn't thought about in years would seemingly randomly surface: the time that a friend in high school decided she didn't like me anymore and I never understood why or what I had done; the time at soccer practice when I was nine and I was chided for thinking I was better than my teammates; and the time a coworker told me that he didn't trust me.

What I fear is that somehow I've gotten this far despite of who I am. The litany of remembered failures and shortcomings, however small, are moments when people were able to see through to the truth of me. At any moment the smoke will clear and everyone around me will be able to see what they saw as well.  One ought to chastise me for even entertaining the thought that the people are around me could be so obtuse for so long, but the quiet fear remains, lurking in the back ground of my thoughts.

And then of course, being who I am, I thought about my own path with coming to terms with my own privilege and being a person of color. Maybe some of those lessons can apply to what it's like to be a new doctor.

Though Robert Jensen wrote this specifically from the point of view of a white person, it has always stuck with me.  He writes,

"A final fear... : The fear of being seen, and seen-through, by non-white people. Virtually every white person I know, including white people fighting for racial justice..., carries some level of racism in our minds and hearts and bodies. In our heads, we can pretend to eliminate it, but most of us know it is there. And because we are all supposed to be appropriately anti-racist, we carry that lingering racism with a new kind of fear: What if non-white people look at us and can see it? What if they can see through us? What if they can look past our anti-racist vocabulary and sense that we still don't really know how to treat them as equals?"

And another little pearl that comes to mind from my friend, Sarah.  As a white woman, she once described her college education and major in African American studies as a mediation on "growing comfortable with being uncomfortable."

I think what I like about these two ideas is that they remind me to accept (or even embrace) my own humanity.  When it comes to race and privilege, I've come to accept that I will never overcome my biases and reach "complete enlightenment."  I don't have any sort of confidence that I can navigate life without offending or disrespecting the people around me.  However, I do find self-assurance in striving for the humility to recognize my own shortcomings and in dedicating myself to self-improvement.

This is not to say that I don't have high expectations for myself and others. I would argue that a lack of expectation, a satisfaction with the low baseline level of discussion and understanding of privilege in this world is one of our biggest problems.  But having high expectations doesn't mean we can't be compassionate when we fall short of them.

We are all flawed.  Perhaps in those moments that I’ve been recently remembering I was unlikable, arrogant, and untrustworthy.  But that doesn't necessarily mean I'm solely those things. Even more importantly, I shouldn't spend energy on covering up those flaws when it could be better spent working on them.

Recently I was encouraged to watch Brené Brown's TED talk, "The Power of Vulnerability" as part of a training on giving and receiving useful feedback.  The entire talk is absolutely worth watching and there are pearls that can be applied to every part of living a more enriched life.  In it she describes her research on how human beings make connections.  One of the fundamental differences that she found between people who tend to have a strong sense of love and belonging versus those who tend to struggle with it is simply the “[belief that] they are worthy of love and belonging.”

Watching her talk was one of those wonderfully clarifying moments where someone has finally figured out how to articulate something you have vaguely perceived all along.

And that just might be the key to being a young doctor (or maybe even a doctor in general).  I will never master medicine in the same way that I will never master the internal biases that I carry.  But as long as I dedicate myself to self-reflection and self-improvement, I have nothing to be ashamed of because I have been adequately trained, I’m dedicated to my patients, and I’m committed to learning.  I am inherently worthy.

True strength is not having lacking any weaknesses, but being able to reveal the weaknesses that you do have. It’s cheesier than a Hallmark card and difficult as hell.  However, being more secure in my own worthiness makes it easier.  No matter how many times I say it, succeed at it, and fail at it, it’s always a struggle because perhaps the biggest catch 22 of all when it comes to “vulnerability” is that as soon as you get comfortable with revealing a certain part of yourself, by definition, it’s no longer vulnerable.

The culture of medicine, as a whole, is toxic. It's built on hierarchy and power.  Theoretically, patient care is supposed to be our highest value.  It is assumed that this is driven by increased knowledge.  Thus, we give the most power to those that can demonstrate the most knowledge.  In reality this creates a pressure to not necessarily know the most, but to conceal what you don’t know.  Mix in the usual amounts of pride, ego, and emotional baggage that colors all human interactions and it’s not surprising that in the end, this structure only vaguely translates to the best patient care possible.  This is the healthcare profession’s greatest shame.

It is also this culture that makes healthcare an incredibly difficult place to be human.  While it’s true that extensive knowledge is necessary, perhaps the framework shouldn’t be that the most knowledge makes the best doctor, but that the best learner makes the best doctor.  Having a doctor that graduated top in their class is less important to me than having one that graduated and continued to learn.

Overall, I think we’re moving in the right direction.  But progress is slow and is still the exception rather than the rule.  Not surprisingly, the shifts in culture that have had the most traction are also the ones that impact the financial bottom line in a positive way.

As I attempt to model my own behavior after my ideals and role models, I’m continually impressed with how hard it is to be vulnerable and confident.  Inherent worth is a dangerous phrase. It's a self-assuredness that can easily transform into over-confidence, arrogance, and entitlement.  Just as difficult is humility.  It is not the masking of arrogance with self deprecation.  Nor is it insecurity or a lack of confidence.  It’s not as simple as a one dimensional spectrum where “insecure” is on one end and “arrogant” is on the other.  There’s no balance, no “sweet spot” somewhere in between.  It’s a presence, it’s a genuineness, that’s on an entirely different scale.

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