The prevalence of imposter syndrome and associated factors in Chinese medical students and residents: A single-center pilot study

Abstract Purpose Here we aimed to define the prevalence of imposter syndrome (IS) and identify associated characteristics in Chinese medical students and residents enrolled at Peking Union Medical College Hospital (PUMCH). Methods This was a single-center, cross-sectional study of medical students and residents enrolled at PUMCH conducted in September and October 2022. Participants were recruited to complete a 37-question survey on demographics, a Chinese version of the Clance Imposter Phenomenon Scale (CIPS), and self-assessments of anxiety, depression, burnout, sleep quality, challenges of clinical learning, and time allocation. IS prevalence and its associated factors were analyzed. Results One hundred and forty-eight medical students and 89 residents completed the survey. IS was significant or severe in 62.8% of medical students and 57.2% of residents. Students enrolled in the eight-year program had significantly higher CIPS scores than those enrolled in the 4 + 4 program (66.4 vs. 60.7, p = .005). There were no gender differences in IS prevalence and severity. Participants with severe IS had significantly higher self-rated anxiety, depression, insomnia, and burnout than participants with mild/moderate IS. Participants significantly challenged by clinical learning had significantly higher CIPS scores. Conclusions IS is both prevalent and severe in Chinese medical students and residents. Classroom learning, an eight-year program, and being challenged by clinical learning are potentially associated with IS.


Introduction
Imposter syndrome (IS), or imposter phenomenon, describes a psychological state of inadequacy, dismissal of one's own achievements, and the belief that one will eventually be exposed as an imposter of success (Mathew and Clance 1985).The concept was first established by Clance and Imes in their 1978 study describing a type of internal experience of "intellectual phoniness", most frequently in high-achieving women (Clance and Imes 1978).
IS is classically believed to be associated with stress, anxiety, depression, and especially burnout (Villwock et al. 2016;Vilchez-Cornejo et al. 2021).Medical workers and students have been the focus of the field since long working hours and high-stress environments are extremely common in medicine.Even though measures have been put in place to restrict working hours in some jurisdictions, attending physicians in Taiwan are still reported to work an average of 50-60 h per week and some over 70 h per week (Chang et al. 2020).Long working hours not only mean that achieving a work-life balance is difficult but they also are strongly associated with burnout (Patel et al. 2018).The proportion of physicians experiencing burnout is significantly higher than in other professions, and over 40% of physicians are reported to be dissatisfied with their work-life balance (Shanafelt et al. 2012).Burnout has recently attracted significant research attention due to its negative impact on mental health and productivity (Dewa et al. 2014).Nevertheless, the characteristics of IS in physicians and medical students are not well studied despite its strong association with poor mental health.
Existing studies on IS in medicine have mostly focused on its prevalence in various specialties and levels of seniority, its correlations with individual characteristics, and qualitative assessments of intervention strategies (Bhama et al. 2021;Fainstad et al. 2022).The most commonly used evaluation tool for IS is the Clance Impostor Phenomenon Scale (CIPS) created by Clance in 1985, which consists of 20 multiple choice questions to assess the individual's fear of failure and negative feedback, feeling of inadequacy, and fear of not living up to other's expectations.The CIPS classifies participants into having few, moderate, high, or intense IS experiences.
Although IS is not a clinical diagnosis, it is clearly associated with mental illness.Most studies suggest that 22-60% of physicians are affected by IS, while a few recent studies report even higher rates (Gottlieb et al. 2020;Regan et al. 2020;Bhama et al. 2021).Studies of medical students have found that IS is associated with female gender, fourth year of medical school, anxiety, stress, depression, and maladaptive perfectionism (Levant et al. 2020;Brennan-Wydra et al. 2021;Vilchez-Cornejo et al. 2021;Shill-Russell et al. 2022).Since IS may harm student confidence, affect feedback receptivity, and limit potential, it is crucial to first understand the basic characteristics of IS to identify those most at risk and to intervene efficiently (Haney et al. 2018;Gottlieb 2021).Although data regarding IS are already available from several centers worldwide, there are little data on IS in Chinese medical students and residents.We therefore aimed to define the prevalence of IS and its associated characteristics in Chinese medical students and residents enrolled at Peking Union Medical College Hospital (PUMCH).We hypothesized that IS is prevalent in Chinese medical students and residents and that certain individual characteristics may be associated with IS.

Study design
The ethics committee of PUMCH approved the study (K2720).Individual consent was implied by participants' willingness to complete the survey.A digital survey containing questions on participant demographics, the CIPS, and a series of self-rated questions was administered to medical students and residents at PUMCH in September and October 2022.Both physical and electronic posters were distributed to reach as many subjects as possible.Based on the survey responses, participant demographics were analyzed and the prevalence of IS and its associated factors were determined and compared for each population.

Participants
Medical students and residents at PUMCH were invited to complete a questionnaire.Medical students included those enrolled in the eight-year combined program (students enter the program after graduating high school to obtain an MD degree) and the 4 þ 4 MD program (students enter the program with at least an undergraduate degree in fields other than medicine to obtain an MD degree).Residents included graduate students, postdoctoral residents, and senior residents who had completed the postdoctoral program.Students and residents did not receive compensation for participating in the study.

Survey
Participants completed a three-section questionnaire containing 37 questions (see Supplementary Materials).The first section collected general information including their gender, age, undergraduate institution, medical education program, stage of study, and current specialty (if applicable).The second section included the Chinese version of the CIPS, in which a score of 0-40 was mild IS, 41-60 was moderate IS, 61-80 was significant IS, and 81-100 was severe IS as previously (Matthews & Clance, 1985).The last section included a self-assessment of the participant's level of anxiety, depression, sleep quality, and degree of clinical learning challenge, as well as an estimate of the number of hours spent on clinical work and learning, research, sleeping, and self-care or entertainment.Furthermore, participants were then provided with the definition and a description of burnout and asked to self-rate their extent of burnout.Chinese adaptations of IS scales have previously been used only a few times (Wu et al. 2022), so the CIPS used in our study was designed by two translators independently to ensure no alterations to the meaning of the original scale.The Cronbach's alpha for the translated CIPS in our study was 0.90.

Data collection
A total of 240 responses were received, and three were excluded due to incomplete information.The final 237 responses included 148 students and 89 residents.The online survey was distributed using the Wen Juan Xing platform (https://www.wjx.cn/), and only one submission was allowed from each IP address.Physical posters with a QR code of the electronic questionnaire were randomly distributed during class meetings, while electronic posters were sent to all eligible class groups.The response rate could not be determined since both physical and electronic QR codes of the survey were distributed to reach as many potential respondents as possible.

Statistical analysis
Data analyses were performed using Microsoft Excel and R version 4.2.1 (R Core Team, Vienna, Austria).Categorical variables are expressed as proportions (%) and were tested with a chi-squared test for independence.Ordinal variables were analyzed with the Mann-Whitney U test.Continuous variables are expressed as mean (M) (standard deviation; SD), with differences tested with Student's t-test or ANOVA.A p-value <.05 was considered statistically significant.

Demographics
One hundred and forty-eight medical students and 89 residents completed the survey, and the detailed demographics of the participants are summarized in Table 1.
Participants were asked to provide information regarding how they allocated their time to their studies, work, and leisure activities.On average, residents spent more hours on clinical work and learning and less time on sleeping and entertainment or self-care than medical students (U ¼ 3543.5, p<.001; U ¼ 8577, p <. 001; U ¼ 8942.5, p<.001), but there was no significant difference in the number of hours conducting research per week between students and residents (U ¼ 6930.5, p ¼ .466)(Table 2).

The prevalence of imposter syndrome in medical students and residents
Among medical students who completed the survey (n ¼ 148), three (2%) had mild IS, 52 (35.1%) had moderate IS, and 93 (62.8%) had significant or severe IS.The prevalence of significant or severe IS in residents was 57.2% (Table 3 Of the 89 residents who completed the survey, 81 residents provided their current specialty.We compared the mean CIPS scores of residents in specialties with ten or more respondents: the mean CIPS score was 57.55 (SD ¼ 13.39) for cardiology residents (n ¼ 11), 62.27 (SD ¼ 11.02) for gastroenterology residents (n ¼ 15), and 69.15 (SD ¼ 10.09) for rheumatology residents (n ¼ 13), but the difference was not statistically different by ANOVA (F(2, 36) ¼ 3.1528, p ¼ .055).However, in post hoc analysis (Tukey's HSD), CIPS scores were significantly higher in rheumatology residents than in cardiology residents (p ¼ .047).
68.2% of medical students and 79.8% of residents reported that they were at least somewhat familiar with the concept of burnout.The mean self-rated burnout scores for students and residents were 2.51 (SD ¼ 0.88) and 2.58 (SD ¼ 0.85), respectively, and the difference was not statistically significant (p ¼ .508).Response data from students and residents were combined and grouped into mild/moderate IS, significant IS, and severe IS based on CIPS scores, and the burnout scores were statistically different between groups (F(2, 234) ¼ 13.45, p<.001) (Figure 1H).The mean burnout scores were significantly different between mild/moderate IS and significant IS (p<.001) and mild/moderate IS and severe IS (p<.001).

Association between the level of clinical challenge and imposter syndrome
To determine whether there is an association between IS and the degree to which students and residents are challenged by their clinical learning, participants were asked to rate how challenged they felt by clinical learning (all aspects of learning relating to a clinical learning environment).Preclinical medical students were excluded from this analysis due to their limited clinical contact.There was no significant difference between the students (M ¼ 6.37, SD ¼ 1.41) and residents (M ¼ 6.37, SD ¼ 1.43) (p ¼ .498).Students and residents were next grouped into feeling mildly (04) (n ¼ 11), moderately (5-7) (n ¼ 122), and significantly (8-10) (n ¼ 24) challenged by clinical learning.The mean CIPS scores were calculated for each group, which were 60.6 for mildly challenged, 62.8 for moderately challenged, and 65.2 for significantly challenged groups, respectively (F(2, 154) ¼ 13.45, p<.001) (Figure 2).The mean CIPS scores were significantly different between mildly and moderately challenged groups and between mildly and significantly challenged groups (Tukey's HSD, p<.001; Tukey's HSD, p<.001).

Discussion
Here we explored the prevalence of and factors associated with IS in Chinese medical students and residents.
We found that IS is both prevalent and often severe in medical students and residents, with significant or severe IS reported in over 60% of participants and only 2.5% of respondents reporting no to mild imposter feelings.Pre-clinical learning and the eight-year program were potentially associated with more significant IS in medical students, while in residents the specialty may be associated with different IS severities.For both students and residents, perceiving a high level of challenge in their clinical learning was associated with more severe IS, but gender and time allocation did not affect IS severity.Furthermore, self-rated anxiety, depression, insomnia, and burnout were higher in those experiencing severe IS, indicating a potential association between IS and mental health issues.
Even though previous studies of IS have been conducted in different populations around the world, producing variable results, our study is the first to focus on Chinese medical students and residents.The published data suggest an IS prevalence of between 22% to 60% in young physicians, while a recent study targeting general surgery residents suggested a 76% prevalence of significant or severe IS in this population (Gottlieb et al. 2020;Bhama et al. 2021).We found that the prevalence of IS was 57.2% in Chinese medical residents, consistent with previous studies.For medical students, previous studies utilizing the CIPS and similar score thresholds revealed an IS prevalence of 30% to 51% (Henning et al. 1998;Levant et al. 2020;Vilchez-Cornejo et al. 2021), lower than our finding of significant or severe IS in 62.8% in Chinese medical students.This disparity might be due to a heavy emphasis on research in addition to clinical workloads in the Chinese medical education system.Indeed, a previous study revealed that Chinese eight-year program medical students generally found research to be stressful and difficult, with over three-quarters of students conducting research motivated by the need to graduate and gain future employment rather than a desire to conduct research (Wan et al. 2022).In other countries, though some students conduct research motivated by academic interest, it is generally not a requirement of medical training (Sobczuk et al. 2022).However, the extent to which stress from conducting research affects the severity of IS in Chinese medical students requires further exploration.
IS was first identified in high-achieving women, and various studies have since confirmed its higher prevalence in women (Villwock et al. 2016;Levant et al. 2020;Shill-Russell et al. 2022).We found that the prevalence of IS and mean CIPS scores were similar in male and female participants, so perhaps the impact of IS in men also needs to be addressed.Furthermore, eight-year program students (CIPS ¼ 66.42, prevalence 70%) had significantly more severe IS than students enrolled in the 4 þ 4 program (CIPS ¼ 60.71, prevalence 51.7%).Eight-year students typically enter the program after graduating high school, while 4 þ 4 students have obtained at least an undergraduate degree in other fields prior to enrollment.Hence, 4 þ 4 students may be more committed to their decision to pursue a clinical career, potentially contributing to lower levels of self-doubt.
It is well-known that IS is associated with various mental health problems (Villwock et al. 2016;Levant et al. 2020;Brennan-Wydra et al. 2021;Vilchez-Cornejo et al. 2021).We found significantly higher self-rated anxiety, depression, burnout, and insomnia in those with severe IS, supporting this potential association.Although a self-reported score is not a perfect replacement for clinical evaluation, it is nevertheless an efficient means to assess a general tendency towards these mental health issues without the need for lengthy questionnaires, which might also decrease response rates and compromise data completeness.Nevertheless, it is possible that participants with more severe IS were  predisposed to overestimating the severity of their mental health problems and vice versa.Hence, future studies should focus on thoroughly evaluating participants' psychological status.
Self-rated scales assessing the degree of challenge have been successfully used to evaluate clinical learning (Rudland et al. 2021).However, previous studies have not explored the association between IS and the degree of challenge posed by clinical learning, which includes various aspects of learning relating to the clinical context (Nordquist et al. 2019).A high level of perceived challenge in clinical learning may cause more stress in participants, which is associated with IS.Our study confirmed that those who felt significantly challenged by clinical learning had more severe IS.However, it is also possible that more severe IS alters the mental state, in turn making clinical learning feel more challenging.Since IS has potentially negative impacts on medical students' and residents' wellbeing, support and mentoring may be particularly important to help young physicians grow both personally and professionally, and several studies have confirmed their benefits (Baumann et al. 2020;Slade 2020;Fainstad et al. 2022).
Our study is the first to report on the prevalence of and factors associated with IS in Chinese medical students and residents, providing new data in this significant population of the global medical workforce.However, our study has several limitations.As mentioned above, the self-rated scales only provide a general impression of the mental status of respondents, and future studies should use standardized assessment tools to further explore the identified associations.Furthermore, our study only recruited students and residents enrolled at one institution, which may not be generalizable to other Chinese medical institutions; multicenter studies are required in this regard.Since both physical and electronic QR code posters were distributed to reach as many participants as possible in our study, the response rate could not be determined, so there may be an unquantified degree of non-response bias.Future studies should use more targeted recruitment methods to reduce bias.Finally, as there are few studies on IS in the Chinese population, future studies could compare its characteristics in different professions in addition to medicine and confirm the associated risk factors and psychological impacts of IS.

Conclusions
Imposter syndrome is both prevalent and often severe in Chinese medical students and residents.Classroom learning, the eight-year program, and experiencing significant levels of clinical challenge are potentially associated with a higher prevalence or more severe IS.Due to its potentially negative impact on young physicians' mental health, further research is needed to identify potential risk factors for efficient intervention.

Figure 1 .
Figure 1.Extreme imposter syndrome is associated with higher self-rated scores of anxiety, depression, insomnia, and burnout.Medical students (n ¼ 148) and residents (n ¼ 89) were grouped based on Clance imposter Phenomenon Scale (CIPS) scores.The mean self-rated anxiety (a), depression (B), and insomnia (C) scores were compared between students in each is group.The mean self-rated anxiety (D), depression (E), and insomnia (F) scores were also compared between residents in each is group.Error bars represent the standard deviation of each mean.(G) Mean self-rated anxiety, depression, and insomnia scores of all participants based on CIPS scores.(H) The mean self-rated burnout scores of all participants were computed for each is group and compared by ANOVA.Error bars represent the standard deviation of each mean.� denotes statistical significance by Tukey's HSD (A-F, H).

Table 1 .
Basic characteristics of the survey respondents.

Table 2 .
Time allocation of medical students and residents.

Table 3 .
Prevalence of imposter syndrome in medical students and residents.