Impostor Phenomenon in Pharmacy Students as It Relates to Professional Identity Formation

• impostor phenomenon
• impostor syndrome
• professional identity formation

Impostor phenomenon was first described by Imes and Clance in 1978.¹ The phenomenon is characterized by a person feeling self-doubt about their abilities and not deserving of their achievements. Several studies in health science students, including pharmacy students, describe a relatively high prevalence of impostor phenomenon.^2,3 One study found that 58% of pharmacy students have either frequent or intense impostor feelings (defined by a Clance Impostor Phenomenon Scale [CIPS] score greater than 61).³ The phenomenon is also common in other professional students, for example, law students.⁴ Impostor phenomenon is frequently portrayed as a problem or presented as a “diagnosis,” and thus frequently referred to as a “syndrome,” which implies that the person experiencing it is a “patient” battling this condition. However, impostor phenomenon is not an official diagnosis listed in the Diagnostic and Statistical Manual of Mental Disorders-5.

At times, this intellectual insecurity may be accompanied by anxiety or depression.⁵ More recently, broader discussions consider whether this phenomenon is a problem of the individual or a societal problem resulting from a misalignment between stereotypical expectations of what “good” or “appropriate” performance should be, and thereby marginalizing those who do not fit into the preexisting mold.⁶ For instance, the leadership qualities expected in a high-level executive often parallel those historically seen as masculine, eg, aggressiveness, decisiveness, assertiveness. Women, who often have a different leadership style and approach than men, may feel out of place in a high-profile position due to colleagues’ conscious and unconscious expectations of what good leadership skills comprise. Addressing a person’s impostor feelings may alleviate some of their ambivalences, but this is not the core of the problem. This example illustrates that it is essential to create professional environments that support diverse leadership models where a variety of individual identities (eg, ethnic, gender) are embraced equally as well as the traditional model where masculine traits are most valued.⁶

Researchers in psychology propose departing from framing impostor phenomenon as the internal insecurities of an individual and instead considering how external constructs, such as the social or professional environments and expectations described in the scenario above, contribute to impostor feelings in some individuals.⁷ Societal, institutional, and interpersonal expectations are rarely discussed but could be key contributors to feelings of discomfort, ambiguity, and anxiety when an individual is attempting to do or learn something new.⁶ In fact, professional socialization early in students’ academic careers can lead to stress and feelings of being overworked, which, while expected during professional training, can contribute to impostor feelings.⁸ Which leads to this question: is feeling ambivalent or unsure of your abilities to some extent a normal part of professional identity formation (PIF)?

Supporting and guiding students in forming their professional identity has recently come into focus within the Academy. The American Association of Colleges of Pharmacy (AACP) Student Affairs Standing Committee encourages inclusion of professional identity curriculum into Doctor of Pharmacy (PharmD) programs. According to the committee’s 2021 report, professional identity “involves internalizing and demonstrating the behavioral norms, standards, and values of professional community, such that one comes to ‘think, act and feel’ like a member of that community.”⁹ Leaders in the medical education have been engaged in discussions about the importance of PIF for over a decade, with one scoping review identifying over 10,000 abstracts dedicated to this subject in the medical education literature.^10,11 PIF is a complex and multi-factorial process that every individual undergoes at their own pace.¹²

Several theories explain how professional identity may be formed. Central to identity formation is socialization, which takes into account a person’s preexisting identity (personal characteristics and experiences preceding admission to the PharmD program, eg, class, education, and sexual orientation) and factors that shape professional identity during the PharmD program (eg, role models and mentors, clinical and non-clinical experiences, self-assessment, formal teaching and assessment, learning environments, health care system influences, “real-life” experiences, and symbols and rituals).⁸ Many of these factors are an active part of curricular and co-curricular interventions (eg, formal teaching and assessment), while others are external factors (eg, healthcare systems in which practice experiences are completed that have different pressures and cultures from those encountered within an academic institution). Professional curricula teach and assess self-awareness, which is integral in the process of PIF. Students need to adequately reflect on their knowledge, skills, and abilities, and self-assess their progress towards becoming a pharmacist. Without growing one’s competence in managing medical therapy, PIF will be severely compromised. But what about other factors? Factors on which curriculum planning and implementation have much lesser influence? For example, how does one start “feeling” like a pharmacist?

Validation theory is a theoretical framework that describes academic and interpersonal validation as important factors in helping students succeed in college.^13,14 Major and career self-efficacy (MCSE) is a common parameter evaluated in student persistence studies. MCSE is student’s trust in their ability to be successful in a specific study area or career trajectory.¹⁵ Multiple studies in enrollment management literature focus on evaluating programs or interventions (for example, implementing career workshops), but few focus on how these interventions are delivered to the students and who would be the most impactful influence on the student.¹⁵ Faculty members have an immense role in helping students form professional identity by providing validation¹⁴; this entails understanding where students are in each stage of their academic journey, connecting with them at their developmental level, and helping them become pharmacists.⁴ It is important to recognize that novice learners can be easily intimidated by new challenges or tasks for which they had little or no preparation; this indicates that practical knowledge and skills are needed before mastery is achieved. While much is discussed in the literature about various strategies that encourage PIF (eg, symbolic socialization, formal professionalism instruction, role modeling), systematic or universal recommendations on best practices are lacking.¹¹

An intangible but likely very influential aspect of helping students build their professional identity while overcoming feelings of inadequacy is how faculty members interact with students in their early and later courses. While some incoming students have had jobs in a community pharmacy setting prior to starting pharmacy school, many first-year students have never interacted with advanced-trained pharmacists before. Thus, their first interactions with their professors help to shape students’ initial feelings about the pharmacy profession (excited, intimidated, overwhelmed, curious, intrigued). Interactions with faculty members throughout their academic journey will either continue to help grow or confuse students’ sense of belonging to the profession and feeling like a competent pharmacist. Students may confuse being inexperienced (low levels of familiarity or knowledge) with being unqualified (low levels of ability).¹⁶ Discussing impostor phenomenon, its impact and prevalence among professionals, and how to recognize it can assist students in overcoming their own impostor feelings.

Law literature suggests that acknowledging the existence of impostor phenomenon and providing an encouraging and supportive environment inside the classroom can create a climate where professional students feel they belong and deserve to be in a professional program which supports PIF. Some authors have suggested that speaking words of encouragement or sending a personal e-mail to acknowledge strong performance (ie, going beyond just assigning a grade) can communicate to the student that they are on the right trajectory to becoming a competent professional.⁴ The encouragement should address not only the quality of the assignment submitted and/or the student’s performance in class, but also how this relates to the student’s future development into a professional colleague.

Mentoring relationships between faculty and students are also invaluable.¹⁴ For example, mentors can help recognize impostor feelings in their students and help shift their thought process from attributing success in a course or on an assignment to pure luck to attributing their good performance to competence, efficiency, and team-building skills.¹⁷ Mentors can shift students’ beliefs by setting expectations that learning is not a continuous upward trajectory, and setbacks are normal during training. These setbacks are not proof of a student not “belonging” in the profession; they are a normal part of learning.¹⁷ These examples support validation theory of helping build MCSE and PIF.

What action can the academic pharmacy community take to help students overcome impostor feelings and make them feel welcome, prepared, and excited about joining the profession? An essential component of our professional identity should include being empathetic and welcoming towards our prospective colleagues who are the future of pharmacy. Creating a safe and supportive environment while maintaining high academic standards, appropriately structured to encourage budding confidence, is of paramount importance. Motivating students to learn, encouraging them to display intellectual curiosity, recognizing their assets (what they know) rather than focusing on their deficits, and developing them in an academically rigorous environment that is respectful and empathetic, without coddling or condescension, are ways to support students who may have impostor feelings.¹⁴ In contrast, learning environments where students are encouraged to compare their performance with their peers, where feedback from a faculty member diminishes the students’ efforts and focuses only on correctness, and where students are afraid to speak up because they fear being exposed can make impostor feelings more pervasive.¹⁷

This Commentary is not intended to diminish the influence of impostor feelings in accomplished professionals who still feel they are inadequate or will be discovered as a fraud; rather, it intends to raise awareness of how we can acknowledge its existence, clarify its roots, and help address it in early stages when students are just starting their professional journeys. Every faculty member has a unique opportunity to help build up confidence and form the professional identity we desire in our graduates, from the first professional year to the last. It is a privilege to be involved in someone’s journey to becoming a pharmacist, and we should strive to take every opportunity to do so.

• Received June 5, 2021.
• Accepted June 29, 2022.

• © 2023 American Association of Colleges of Pharmacy