I was terrified. It was my first night shift with the prefix “Dr.” proudly adorned before my name, and though I’d feigned a confident start as I’d strapped the on-call pager to my belt, I felt like a total imposter. Years of medical school had assured me that I’d be ready when this moment came. All the doctors I’d shadowed had always appeared so confident. My mask of self-assurance and control was shared by my colleagues—impenetrable to those from the outside. I had no idea that I was not actually alone in my sea of uncertainty.

At 2am my heart rate sky-rocketed with the less-than-dulcet tone of the pager. Gingerly I dialled the number and was informed that a patient had painful hemorrhoids which seemed now to have become my problem. I put down the phone and panicked. I had no idea what to prescribe. While I could have written an essay on the pathophysiology and long-term surgical management of hemorrhoids, what to prescribe at 2am had never been an exam question, and its answer, therefore, was not in my memory bank. I did, of course, recognize that this was not a life-threatening emergency, though ironically this made me feel more alone as asking for help seemed far less acceptable. I felt there was only one person to whom I could admit “I don’t know”. And so, at 2.30am, I rang my father (a physician) from the broom-cupboard.

Retrospectively I realize in that moment I was tapping into a place where I could expose my uncertainties and insecurities without fear of judgment or perceived incompetence—a place of “psychological safety”. I have since learnt that this concept, defined as “being able to show and employ one’s self without fear of negative consequences of self-image, status or career”, is at the core of successful team functioning. [1] Too often, however, it is missing from the healthcare environment which may be contributing to the acceleration of faculty dissatisfaction and burnout.

A culture of psychological safety and openness, where team members feel accepted and respected, has been shown to play a vital role in helping people thrive in challenging and high-stakes work environments. [2] Unfortunately, it is often elusive in the healthcare setting where a salient hierarchical structure and powerful professional norms may threaten an ability to speak up or ask for help. Aside from improving physicians’ sense of comradery and community, likely to positively impact wellbeing, psychological safety has been shown to be a crucial element in organizational efforts to detect and prevent patient harm by errors and process failures. [3] Healthcare should be its poster child.

Considering the fluid nature of human capital as trainees rotate through healthcare environments, with shift-pattern work structures and reduced duty hours, we need to understand how to create psychological safety and openness in work groups with changing membership. We need to create a culture that helps to promote discussion of insecurities and uncertainties, ensuring community members feel respected and included, while striving for high performance. We need to recognise the difference between incompetence and uncertainty and ensure that psychological safety is created for those early in their careers who lack power or status, but need support and security the most. Role-modelling embracing the inherent uncertainty of clinical medicine helps set a new culture that normalizes the experience of admitting “I don’t know”. [4] 

These simple words welcome input and curiosity, a fundamental motivator for learning, pivotal to the development of sound clinical reasoning. Uncertainty is, after all, a certainty in medicine. [5] We must ensure we are resting, not wrestling, with it.

As humans, we evolve on a millennial timescale though our task is to keep up with an environment that changes, comparatively, at the speed of light. One challenge of the fast-paced, technology-driven environment that is rapidly growing around us, is the imperative to stay connected personally—not electronically—and reduce isolation. Intentional efforts to establish and nurture social and supportive environments—modifiable factors for all organizations that require relational, rather than financial, investment—will be ever-more critical in the years ahead. [6] Embedding the importance of “good human connection” early in medical education is essential—both for high quality patient care, and to boost and protect faculty wellbeing. It has been shown that creating space for physicians to bond over shared experiences and reflect increases empowerment and engagement at work, and decreases burnout. [7]

A collateral benefit of promoting a culture that epitomizes psychological safety and openness is the potential to start mitigating the “imposter syndrome” that is all too prevalent in medicine where perpetual appraisal is the norm. This form of inaccurate self-assessment breeds in environments where individuals do not feel able to speak up and consequently assume that they, alone, do not belong. [8] Self-doubt is exacerbated in situations where confidence must be shown, but is not felt. A feeling of “wanting to impress” lingers—a feeling that has been hard-wired through years of medical training, often self-selective for a medical career. Creating teams where admissions of perceived weakness are celebrated, ironically, leads to higher performance and develops opportunities that transforms failure into a teaching tool. This notion must be embedded into the healthcare culture, for self-doubt affects all career stages. Perceived competence doesn’t necessarily follow once actual competence is achieved.

Fostering an atmosphere in which trust and respect thrive, and flexibility and authenticity flourish, pays off in most settings. We must now turn to our fellow healthcare professionals and call on them to join us in the quest to nourish the comradery and community that forms the backbone for patient care of the highest quality and safety. 

Arabella L Simpkin is an assistant professor in medicine at Harvard Medical School. She is the associate director of the Center for Educational Innovation and Scholarship at Massachusetts General Hospital and is currently completing a DPhil in Pharmacology at the University of Oxford looking at uncertainty and the impact it has on burnout in healthcare professionals.

Twitter handle: @greyscalespaces

Competing interests: None declared

References:

1. Kahn WA. Psychological conditions of personal engagement and disengagement at work. Academy of Management Journal 1990;33:692-724.
2. Edmondson AC. Psychological Safety and Learning Behavior in Work Teams. Adminstrative Science Quarterly 1999;44:350-83.
3. Edmondson AC. The kinds of teams health care needs. Harvard Business Review 2015:2- 5.
4. Gheihman G, Johnson M, Simpkin AL. Twelve tips for thriving in the face of clinical uncertainty. Med Teach 2019:1-7.
5. Simpkin AL, Schwartzstein RM. Tolerating Uncertainty – The Next Medical Revolution? N Engl J Med 2016;375:1713-5.
6. Simpkin AL, Chang Y, Yu L, Campbell EG, Armstrong K, Walensky RP. Assessment of Job Satisfaction and Feeling Valued in Academic Medicine. JAMA Intern Med 2019.
7. West CP, Dyrbye LN, Rabatin JT, et al. Intervention to promote physician well-being, job satisfaction, and professionalism: a randomized clinical trial. JAMA Intern Med 2014;174:527-33.
8. LaDonna KA, Ginsburg S, Watling C. “Rising to the Level of Your Incompetence”: What Physicians’ Self-Assessment of Their Performance Reveals About the Imposter Syndrome in Medicine. Acad Med 2018;93:763-8.