This is so painful. How long has it been, like 30 minutes??
Glancing at my phone, the digital clock read 3:15 pm.
Damn. Only 10? I don’t think I can do this.
My gaze spilled over the Neonatal Resuscitation Program textbook splayed out in front of me, my illegible scribbles in the margins serving as a reminder of how much I was failing to remain engaged. Even forcing myself to write out MR SOPA wasn’t enough.
Of all the things you’ve studied, you know this is the thing that actually matters. Get your shit together, M! You studied for 2 board exams 3 months apart – you can sit down for 4 hours to review something you already know.
Letting out a huge sigh, I leaned forward and placed my elbows on the wonky coffee shop table, feeling my world shift to the right. I almost willed the black coffee in my mug to spill over, just so I’d have an excuse to get up and escape from the next 200 pages of my textbook.
No dice.
Returning to the picture on the page of an angry, pink baby with a T-piece resuscitator hovering over its face to supply oxygen, I was immediately transported to another place, three and a half years ago.
Except that baby was limp and gray. Slippery in the warmed blankets that didn’t seem to be able to contain her. Listless despite the efforts to stimulate her to breathe, turning bluer by the second.
“Why isn’t she crying?? What are you doing to my baby?!?”
Mom’s wails rang out in my right ear as if it were yesterday.
“Pulse ox needs to be on the right wrist, not the left. What’s her heart rate?”
“85.”
“Start PPV.”
Breathe, two, three. Breathe, two, three. Breathe, two three.
Page 77: When providing positive pressure ventilation, rate should be 40-60 breaths per minute.
Somehow those words on the page didn’t capture the excitement and terror of being the only pediatrician in a little Michigan rural hospital.
I had signed up for a 6 day stretch of newborn nursery coverage, living in a hotel across the street. Moonlighting to earn extra money to finance my move across the country to the west coast seemed like a good idea at the time. Who wouldn’t want to cuddle newborns all day and play a part in parents’ happiest day of their lives?
The other weekends I moonlighted had been easy peasy – some weekends didn’t have any babies at all! My sister and I would hang out in my hotel room hating on people on House Hunters and watching bad movies on TBS.
This week was different.
3 botched home deliveries in the last 48 hours, each time urgently paged in by the midwife. The slowing pitch of decelerating fetal heart tones greeted me every time I came in the room to introduce myself – a tell tale sign things weren’t going well.
The other two babies perked up just fine with a little pat on the bottom and required only some monitoring to make sure they were replacing the amniotic fluid in their little lungs with air.
But not this one.
This one refused to breathe, even with utilizing my MR SOPA acronym laid out in the book:
- Mask readjustment ✔️
- Reposition airway ✔️
- Suction mouth and nose ✔️
- Open mouth ✔️
- Pressure increase ✔️
- Alternative airway
Full term babies: size 1 straight blade, 3.5 endotracheal tube. Stylet optional.
Running through the checklists in my mind in the comfort of a coffee shop did nothing to reflect the mental preparation it took to ready myself for my first baby intubation away from an attending’s watchful eyes.
“Do you see chest rise?”
“No chest rise.”
“Increase the PIP to 30.”
Breathe, two, three. Breathe, two, three. Breathe, two, three.
Finally the spark of movement over the baby’s ribs began to show. Her heart rate and oxygen levels started to rise on the monitor. As she began to angrily shriek, I finally let out the breath I didn’t realize I had been holding.
“Keep her on CPAP for now. How long did she need PPV?”
“2 minutes, Dr. M.”
Who knew eternity could stretch out in the span of two minutes?
Despite giving her respiratory support for 15-20 minutes, we still couldn’t get this little one to breathe on her own without significant increased work of breathing. Realizing I had to transfer her to the NICU of the hospital I had just graduated from, I dreaded the feedback I was going to get from the NICU team upon their arrival.
How quickly would it take me to transition from my signout to rambling apologies?
Sorry you had to come all this way.
Sorry I didn’t feel comfortable enough to keep this baby on CPAP all day.
Sorry I couldn’t fix her.
An hour and a half later, I caught glimpse of a familiar shock of auburn hair walk through the door.
“M! We thought that was you who called. Nice to see you!”
“Thanks for coming, K. I hate to say this, but we were able to get her off CPAP 10 minutes ago but didn’t know how to contact you. You can still check her out in the nursery though.”
After K completed her evaluation, I couldn’t help but blurt the words out to her, the neonatal nurse practitioner I had worked with on long NICU nights during rapid response calls.
“I’m sorry you had to come all this way… I know it’s a long drive. I should’ve just waited a bit longer before I called you in.”
K straightened her back and regarded me.
“M… do you know what Dr. O said when he got off the phone with you? He said, ‘I think that was M, one of our recent grads. If she’s calling, then you know it’s for real.’
I know you made the right call with the information you had in that moment. Don’t double guess yourself now.
At the end of the day, she’s still alive.
Because of you.”
Impostor syndrome
Jolted back to here and now by the barista wiping down tables, I realized why I was back on the struggle bus – even after three and a half years into being an attending, I still feel like a fraud. That, and the imagery of being handed over a blue baby is something I will never get out of my head.
In the International Journal of Behavioral Science, Sakulku and Alexander state, “It is estimated that 70% of people will experience at least one episode of Impostor Phenomenon in their lives.”
Dr. Young categorizes Impostor syndrome down further into 5 sub-groups:
- The Perfectionist
- The Superwoman/man
- The Natural Genius
- The Soloist
- The Expert
Unfortunately I’ve become familiar with all 5 ways of feeling like an impostor over my short lifetime, and now it’s flaring up again just in time for me to jump into the next phase of my career.
How can I have the audacity to think I could resuscitate a baby again, three and a half years out from my last attempt?
How can I possibly think that I could just easily slip back into hospitalist medicine and pick up where I left off?
How could I have allowed myself to leave the comfortable confines of my outpatient office, to abandon what I know I’m good at to go off into the unknown?
“You are bold and courageous,” a reader once messaged me.
Is that truly what I am?
Or am I just so naive I still think I can handle anything?
Perhaps what they’re confusing for boldness and courage is my desperation and grasping at straws to find something, anything to help get me unstuck in my burnout struggle.
Now with reality staring me in the face, my confidence in the “right-ness” of my decision to leave has crumbled, leaving me with this one question:
Are you sure you know what you’re doing?
“Remember when you’re a doctor, you need to know what you don’t know,”
I once told my old scribe, A.
“Don’t be that jerk who thinks they know everything. Because that’s literally impossible.”
OK, M. Time to take your own advice for once.
77 pages down, 200 more pages to go.
You won’t know everything, but dammit, you’re going to know this.
***
Have you ever struggled with impostor syndrome? If so, what did you do to combat it? Leave a comment below!
***
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I can absolutely relate. I suffer from a lot of imposter syndrome clinically. It seems that people around me think that I’m pretty good at my job. I just keep waiting for them to find out I am a fraud.
At least I am not at the peak of “mount stupid” (Duning-Kruger effect).
🙂
P.s. good job saving that baby!
TPP
How many awards and publications does it take to cure imposter syndrome? Asking for a friend 😉
I find it so fascinating that so many people I hold in high regard struggle with this. I wish it were only isolated to my abilities in medicine, but as I published this post last night, I had an inkling that this one wasn’t good enough to publish.
Who am I to continue writing?
But we keep doing what we do anyway… maybe it’s realizing we’re not at the peak of “mount stupid” that keeps us going.
With my job change I’m feeling very similar! I’ll have to do LPs ( haven’t done that in years), NG tubes ( same as LPs), urinary cath (whoops, skipped that one),IVs in babies (oy vey).
I too will be the only pediatrician in the hospital and seeing kids in the ED as they get called for admits. I’m not a fan of EDs and will have to go down there and make ED type decisions that I have thought about in years!
The other day one of my residents recognized a less obvious presentation of anaphylaxis (a little bit of hives and emesis). He saved that babies life. And that’s what I told him.
Like him, your actions saved a baby’s life. Someone’s perfect little baby is not dead because of you.
We all have these experiences and they can become so “routine” that we forget how incredible it really is and that not anyone can do these jobs. That even though we can feel the imposter at times we are still kicking ass.
I thought of your job change when I wrote this! Working in a rural setting without any backup is absolutely terrifying when you realize you’re it!
My husband last night laughed at me when I told him I was writing about impostor syndrome since I was unsure about my abilities for my upcoming job. He told me, “Even if you don’t remember how to do these things right now, you’re good at learning and doing whatever it takes to get where you need to be.”
Sometimes we just need to be reminded of that once in a while.
You’re still kicking ass 🙂
Bold and courageous is just another take on recognizing someone who is appropriately scared and has a work ethic.
It’s the latter imposter I want taking care of my loved one every time.
“Appropriately scared.”
That was pretty much my only requirement of my interns when I was a senior resident. That meant they were teachable and ready to put aside their egos in order to learn.
It’s a fine line to walk – I think most of us feel more comfortable underestimating our abilities because overestimating them can cause a whole lot more trouble.
Hey M,
I feel that pretty frequently actually. To me, it suggests that I am actually engaging with what I am doing and trying to figure out how I could do it better next time. As a resident later in my training cycle, I frequently work with both 1st and 2nd year residents and am the senior on call at nights with no faculty in house. We have to make decisions very similar to what you describe, and if you actually take your own pulse and do some self analysis, thoughts similar to yours go through my mind all the time. For instance, we had to check out a patient to an ICU attending who is notorious for asking very difficult questions and expecting things to be “just right” when they are handed off to him. A younger resident and myself ultimately had to call this ICU team several hours after we had done everything we could reasonably think of on this lady, and yet she wasn’t responding appropriately, and would more or less go in and out of consciousness. Yes, she had liver disease, but her blood alcohol level was very low and metabolically, she didn’t look that shitty on paper. Long and short, we did what we were capable of on the floor, and to do what felt like the most reasonable and appropriate next step for this patient, called ICU. Turns out, this attending was on and actually came to the handoff. I calmly explained my thought process on this lady, what we had done, and why we believed she needed a higher level of care (and 1:2 nursing care) which you cannot get on the normal floor. Turns out, he had NO additional questions for us, and stated we had done a very good job up to this point, and had managed it essentially how he would have. That meant something coming from this NO bullshit type of guy who has been practicing for ages, and to me confirmed that even in medicine, you must trust your gut. At the end of the day, I remind myself that a wrong “call” you make for the best of intentions is far better than the call you don’t make because you are scared of the consequences. Whether that is embarrassment, shame, pride, etc., I remind myself that my job is to do what I think is best for my patient. My pride and ego (no matter how small) will heal, but a septic patient doesn’t heal without some additional care or antibiotics :). Keep up the good work M, and trust your gut!!
SK,
I am so sorry for the delay in responding – your comment somehow made it in the trash, so fortunately I rescued it from there!
We all need to have a healthy dose of fear – it keeps us on our toes. It’s when fear becomes that obstacle to your next move that it becomes a problem. I’m glad you’ve learned to harness this for the better! It’s a skill that you hone well as a senior resident – remember that when you’re an attending. The fear definitely changes but the way you harness it stays the same 🙂
Best,
M
I honestly think everyone has a bit of imposter syndrome hanging over them.
No matter how much knowledge you can possess there is so much more that we don’t know.
I much rather have a physician that recognizes his or her limitations because those are the ones they seek help when needed. Compare that to the physician who let’s his or her ego get the better and you will find someone who refuses to recognize limitations and make mistakes because of it.
I agree 100%! I love that TPP brought up the Dunning-Kruger effect – someone actually spent the time to quantify this!
This is why they call it practice. Eventually you get good, then amazingly good, then you become the goto person because you simply know what to do, and do it correctly, effortlessly, in a heartbeat. It sounds like ego. It sounds like bravado but it’s neither. It’s maturity. The process of becoming mature is iterative. Maturity is not the thing that burns you out, it’s the thing that relieves burnout.
There is much to be said for experience!
Few things are more humbling than caring for a dead or dying kid. When I look back over the past decade of working in an E.D., it’s the sick kids that have been the main source of my second guessing and sleepless nights.
I agree with Gasem that these skills get sharpened with time. Although the impostor syndrome never truly goes away, it takes longer and longer hiatuses.
It is only natural to suffer more imposter syndrome as you start this new phase of your career. That nervous sweaty gonna-puke feeling in the pit of your stomach is growth. No one ever got stronger by staying in their comfort zone. Go kick some butt! (metaphorically. Hospital admins frown on kicking newborns)
I’ll be sure to not kick any newborns.. I think parents also frown on that in addition so hospital admins 🙂
Thanks for the well wishes!
When we make a call by instinct or reflex, we feel like a fraud because we were not aware of a thought process. It feels like a lucky guess. The truth we should recognize is that we can be skilled to the level that we observe the patient, assimilate the data, discern the issues, and make a decision on a subconscious level. It can be fast and decisive, looking like an impulse.
How many times does it turn out to be an out-of-the-box solution ? How many times does it work out well ? We are not frauds; we are masters.
“We are not frauds; we are masters.”
I love this! It’s true – when you start moving from overthinking to now reflexively responding to situations, you move from novice to expert. Thanks for the reminder 👍🏽
I want to comment, but I’m afraid that I am not qualified to post to a Doctor’s blog. I’m an independently practicing CRNA, and so my particular brand of impostor’s syndrome lies somewhere between the superwoman/man and the soloist. As a non-physician provider practicing for approximately four years I am making the transition from competency to expertise, and I think that transition was very much attended by the traits listed in the Forbes article listed above. I believe as Heidegger did that as any work is mastered, the workman dissolves in the work; in the act of hammering, the craftsman and the hammer become one. Similarly, the way beyond imposter syndrome may be to shift the emphasis of care beyond the titles, prejudices, and expectations in such a way that work, patient, and provider flow together in a world that takes improvement as its singular characteristic.
No qualifications needed to post here – thank you for commenting!
I agree – there is always room for improvement and we should always strive for growth. Impostor syndrome is fascinating to me because even people who most would consider accomplished, like Maya Angelou as one example, fall prey to this. It’s an internal battle thus I’m not sure how influenced it would be by external pressures, but I do think it possibly propels people TO self-improvement. We just need to be careful that it doesn’t ruin us in the process.
I love this! I have felt imposter syndrome being a mother so often. I stumbled across your blog and have been very sobered up by it. So, thank you. I have recently felt a strong call to become a doctor but want to be careful about my idealism going in. I have experienced so much poor doctoring (which I define, in my little experience, as not being willing to have a conversation with an open minded patient about science and why things work and don’t work (vaccines most importantly —I am pro vaccine, but spent 5 years waffling back and forth on the issue because 3 pediatricians I saw refused to even have a conversation about it with me even after I said, “I am on the fence about vaccines. Can you give me any solid literature to read on the issue?”—)).
Anyways. My OB is the only one who even was willing to have a conversation about vaccines, which is something he doesn’t get paid for. I am forever in his debt and so thankful for his sacrifice of time for little return on his end.
Thank you for this blog and putting yourself out there like this.
Cari,
Thank you so much for your comment and for reading! I always find it fascinating when non-medical people read this stuff, and I’m curious to know what’s going through their heads!
I’ve been torn on whether or not I should discourage people from a career in medicine (I’ve written quite a few posts on it, especially about my old scribe), and I’ve ultimately decided that it’s not my place to discourage anyone. It IS, however, my responsibility to make sure people go into this with their eyes wide open. I want to make sure they understand their motivations for going into the profession, because it does take a lot out of you and if you’re not ready for ALL of it, then I encourage them to find other ways to fulfill their need to help others. This requires being truly honest with yourself, and sometimes that can be a hard thing to do.
Medicine becomes part of your being, and try as I may, I will never be able to separate myself from Dr. M. I spent too many formative years pursuing this career.
Please don’t lose your idealism – there is something beautiful and precious about being able to see the good and the potential in the world and in others. We talk about being idealistic in such coarse and cynical terms, but truthfully, there would be no dreams left to move forward to if we all turn our backs on our idealism.
Best,
M