By Arthur Lazarus, MD, MBA 

Paul Simon, one of the most successful singer-songwriters in the world, feels insecure. In "Fakin' It," which appears on the fourth Simon & Garfunkel album Bookends, he sings: "I know I'm fakin' it. I'm not really makin' it...This feeling of fakin' it, I still haven't shaken it." Simon leaves the listener believing he may have been a tailor in a prior lifetime. Talk about imposter syndrome!

Imposter syndrome plagues approximately 30% of medical students and residents. The hallmark of imposter syndrome is a feeling that one is a fraud and not worthy of their achievements. However, the syndrome is somewhat of a misnomer, because physician imposters never really doubt who they are -- at least not in terms of Erik Erikson's definition of identity, which he believed developed over a lifetime and was an amalgamation of one's experiences, beliefs, values, and memories that shape one's perceptions of self.

Although most students enter medical school with a strong sense of identity and a conviction to become a doctor, some become lost and disillusioned, uncertain of who they are, and contemplate alternative careers. Only about one quarter (27.9%) of medical students stick with their original preferred medical field or specialty throughout medical school. They begin to doubt their abilities and question their destiny. Like Simon, they resort to faking their way through medical school to please others or just to get by.

How do I know this? Because I was one of those students. And in my 40-plus years of mentoring medical students and residents, I can assure you a significant percentage of them have high anxiety and doubts about getting through medical school and residency. In fact, about one in three medical students globally have anxiety -- a prevalence rate that is substantially higher than the general population.

According to Pamela Wible, MD, an expert in physician psychology, many doctors lack self-confidence. They pretend to have all the answers, and they have learned to become masters of disguise, lying not only to patients and other doctors, but also to themselves -- for example, lying about their mental health by concealing substance use and suicidal ideation. In the "fake it till you make it" culture, Wible writes, "[f]ake smiling happy med students and happy doctors die by suicide at alarming rates."

Sadly, approximately one doctor per day dies by suicide in the U.S. Suicidal ideation is highly prevalent in medical students, where rates of depression are 15 to 30% higher than the general population. Despite poor mental health, the overwhelming majority of students slug through school, suffer in silence, and manage to graduate on time.

My own unhappiness led me to question the odds that students will complete all 4 years of medical school (consecutively). The answer came in 1995, when I was in business school. The topic was the focus of a project I undertook for a course in quantitative methods. One of the associate deans of my medical school was kind enough to supply data that I could plug into a Markov analysis. I calculated that 91% of students will graduate in 4 years (nowadays it's in the range of 82-84%).

But my analysis could not possibly have captured the anguish and uncertainty endured by many medical students, the kind that forces them to fake their way through school and later in residency programs and practice. There's actually a name for this state of mind, and it's not imposter syndrome. Rather, it's called uncertainty tolerance, or "UT" for short. Uncertainty tolerance is a psychological construct referring to the way an individual perceives and processes ambiguous information and situations. Uncertainty is inherent in virtually all aspects of medical practice, and the manner in which students and physicians deal with it affects their emotional well-being.

Low UT among physicians has been linked to negative healthcare outcomes, including less favorable attitudes toward patient-centered care and increased risk of burnout. On the other hand, high UT appears to be protective against oneself and declining attitudes toward underserved and poor patient populations. Medical students who are more intolerant are less likely to practice in primary care or resource-limited settings. However, the clearest association is between medical student and physician UT and their psychological wellbeing, with lower UT associated with higher rates of psychological distress and mental health disorders.

Medical students will suffer less anxiety if they can learn (or be taught) to tolerate ambiguity. Reducing students' anxiety is important because it is tied directly to their sense of worth and purpose, and may influence their career choice. Anxiety is at the root of many situations where individuals feel as though they have to fake their way through them.

This begs the question: what can medical schools do to ease students' anxiety around ambivalence and uncertainty? Can they prioritize and incorporate elements of ambiguity and uncertainty into an already jam-packed curriculum?

Several suggestions have been offered including, but not limited to: (1) acknowledging the anxiety related to uncertainty and addressing it by supporting students rather than attempting to "fix" or "solve" specific problems; (2) holding professionalism seminars and courses that include faculty-facilitated small-group discussions about ambiguity and uncertainty; (3) teaching students about the fundamental nature of medical practice, i.e., some degree of anxiety is natural, predictable, and to be expected; and (4) having students engage in reflective writing exercises. Indeed, there has been tremendous growth and interest among medical schools in narrative medicine writing.

Greater control over and understanding of uncertainty in medical practice lessens anxiety in medical students. It gives them greater comfort, suffuses them with purpose, and replaces thoughts of feeling like an imposter with feelings of genuine worth, bolstering their ego and identity. Under these conditions, the need to fake any behavior is reduced. As one medical student put it: "when it comes to mental illness, a prescription to fake it is never going to make it."

Nearly 20 years after Simon wrote "Fakin' It," and after bouncing back from his depression, he revolutionized rock music with the release of Graceland. Perhaps he was a doctor rather than a tailor in his prior existence.

Arthur Lazarus, MD, MBA, is a member of the Physician Leadership Journal editorial board and an adjunct professor of psychiatry at the Lewis Katz School of Medicine at Temple University in Philadelphia.