“Imposter phenomenon” – the phenomenon of feelings of persistent self-doubt, or fear of being found out as a fraud – has attracted much attention in recent years. It encompasses a wide range of experiences and is said to be commonly experienced by healthcare professionals. Solutions to imposter phenomenon frequently emphasise ways in which individuals can reframe their thought processes. But what about situations where the idea that we are an imposter isn’t ‘all in our head’ but rather something that is fed back to us – either explicitly or implicitly?
I experienced such a situation this summer. I had tweeted a thread detailing thirteen health conditions in which Black and Asian communities had worse outcomes than White communities in the UK, to illustrate that ethnic inequalities in health existed well before COVID-19. One of the first reactions was someone quote-tweeting me with the words “Is this true and has it been medically fact checked?” I had referenced each statistic with a link directly to the cited paper, and had used my full name with Dr as my title, as well as my position and the NHS trust where I work, in my twitter profile, so this was an unwanted surprise. My partner, a philosopher, helpfully told me I had been regarded as having a “credibility deficit” and had experienced a “testimonial injustice”.
The term, testimonial injustice was coined by philosopher Miranda Fricker and is a type of epistemic injustice, or wrongdoing related to knowledge 1. Testimonial injustice occurs when the listener discounts the credibility of the speaker’s word due to prejudice about their social identity, and is often associated with gender, ethnicity, class, sexuality or religion. The speaker experiences a credibility deficit. Fricker argues that the problem, and potential solutions require us to pay attention to relationships between individuals. In contrast, the term “credibility excess” refers to those whose word is more likely to be regarded as rational, competent and therefore credible, due to their social identity. In medicine for example, they may be doctors who regularly speak with confidence about conditions outside of their specialty in public forums.
My twitter example is relatively mundane. However, the concept of who is and isn’t seen as credible can have much wider impacts on the allocation of resources, the distribution of knowledge and the medical workforce, all of which can seriously affect the health of patients 2.
Individual patients experiencing testimonial injustice may find that their symptoms are not believed or taken seriously. For example, the review into the vaginal mesh scandal this year, reported that the denial of women’s concerns led to years of unnecessary suffering. Patients found their symptoms were dismissed as “psychological” or as “normal women’s problems”. Endometriosis, a common menstrual disorder with pain as a main symptom, takes on average 7.5 years to diagnose and again, patients often report clinicians do not take their concerns seriously. There is evidence to suggest that women experience testimonial injustice more often than men and this is exacerbated for women from ethnic minority backgrounds. It’s possible it may contribute to some of the stark ethnic health inequalities we see, such as in maternal death rates.
Within the workplace, a common example of testimonial injustice occurs in meetings; a speaker’s points are ignored, only for another more credible (but not necessarily more competent) speaker to make the same point later on and be praised for it. Gallagher et al suggest that if a person experiences incidents of testimonial injustice frequently, it may deter them from speaking up in the future meetings and may erode their intellectual confidence. This can be detrimental to their careers in the long term, serving as a barrier to pursuing opportunities to sit on boards or apply for leadership positions. If this experience occurs more frequently to women or minoritised groups, it may result in their views or opinions being lost from the discourse, which is particularly important in decision-making bodies that determine the allocation of resources such as funding boards, and the distribution of knowledge such as editorial boards. Disease areas that may be more likely to be prioritised by women and minoritised groups may not receive the funding or attention they need, further embedding patterns of historical marginalisation2. An example of this may be the health research gender gap, where despite a third of women experiencing a reproductive or gynaecological problem in their lifetime, less than 2.5% of publically funded research is allocated to this field.
Testimonial injustice can also undermine diversity and inclusion initiatives, as increasing the representation of certain groups on boards does not necessarily result in their voices being heard and taken seriously.
There are no simple solutions to testimonial injustice, as challenging societal prejudices and stereotypes takes time. However, actions that seek to promote the voices of those historically less heard and less valued would be a good start. For example, The British Philosophical Association and Society for Women in Philosophy Good Practice Scheme contains recommendations on how to chair a seminar so that more voices are heard. This includes not necessarily picking questioners on a first-come-first-served basis, which favours those who are quicker to put their hands up, and taking a short break between the talk and the questions so people who are less sure about their question, have time to think it through. These recommendations could be easily adapted to teaching sessions or conferences in medicine.
So how does this relate to imposter phenomenon? I offer a personal example of feeling this when I was redeployed to work on COVID-19 wards earlier this year. Working on an unfamiliar ward with a new team whilst wearing scrubs for infection control purposes, meant that I was often mistaken for more junior staff, whilst my junior colleagues were often treated as the consultant. I now see that perhaps this wasn’t imposter phenomenon that I was experiencing, but rather a credibility deficit. There may well have been instances where I was perceived to not fit the stereotype of what a consultant looks like, whilst my white and male registrars did.
Imposter phenomenon is often seen as the problem of the individual, which the individual must work to overcome – solutions thus focus on building confidence. But if what we are told is imposter phenomenon is actually repeated instances of testimonial injustice, then this requires collective, not merely individual, solutions. Whilst there needs to be a shift in how societal prejudices and biases are shaped and perpetuated to reduce testimonial injustice, this may be slow. We can start in healthcare by ensuring that groups with the power to make important decisions about resource allocation and knowledge distribution are not only diverse, but proactively make efforts to ensure everyone’s voices are valued and heard. This would greatly benefit our patients and our workforce.
- Fricker M. Epistemic injustice: power and the ethics of knowing. Oxford University Press: Oxford, 2007
- Gallagher S, Little JM, Hooker C. Testimonial injustice: discounting women’s voices in health care priority setting. Journal of Medical Ethics Published Online First: 24 April 2020. doi: 10.1136/medethics-2019-105984
Dr Rageshri Dhairyawan
Dr Rageshri Dhairyawan is a Consultant in Sexual Health and HIV Medicine at Barts Health NHS Trust, London and a Honorary Senior Lecturer at Queen Mary University of London. Her work focuses on improving care for marginalised populations living with HIV. She is an elected trustee of the British HIV Association and SWIFT women which focuses on women living with HIV. She also sits on the medical board of NAZ, a charity specialising in the sexual health of ethnic minority communities.
Declaration of interests
I have read and understood the BMJ Group policy on declaration of interests and declare the following interests: none.