Distribution of imposter syndrome among medical students of Bangladesh: a cross-sectional study

Introduction

Imposter syndrome (IS) is characterized by a feeling of not belonging, out-of-placeness, and the belief that one’s perceived competence and success by others is undeserved. Usually, this is considered an individual problem that should be addressed by keeping a record of accomplishments as a reminder of progress (Breeze, 2018; Mak et al., 2019; Hendriksen, 2015). In late 1978, clinical psychologists Pauline Clance and Suzanne Imes first cited the IS which arbitrated the relationship between perfectionism and anxiety and partially influences perfectionism and depression (Clance & Imes, 1978)

A more recent systemic review conducted in the U.S. in 2020 found that the prevalence of IS ranged from 9% to 82% in the general population (Bravata et al., 2020), while another review conducted in the U.S. in 2020 found that it ranged from 22% to 60% among physicians and from 33% to 40% among trainee physicians (Gottlieb et al., 2020). In the United States, recent studies on IS have found that 57% of pharmacy students (Sullivan & Ryba, 2020) and 15% of medical students have IS (Holliday et al., 2020). Indeed, IS is becoming a growing public health issue both globally and regionally. For instance, the prevalence of IS among medical students has been found to be 30% in the US (Villwock et al., 2016), 45.7% in Malaysia (Ikbaal & Salim Musa, 2018), and 47% in Pakistan (Qureshi et al., 2017).

Several studies suggest that IS has a strong correlation with general psychological distress (Bravata et al., 2020; Sullivan & Ryba, 2020; Wang et al., 2019) and demographic and personal characteristics, including age (Bravata et al., 2020; Holliday et al., 2020; Sullivan & Ryba, 2020), gender (Gottlieb et al., 2020; Holliday et al., 2020; Rosenstein et al., 2020), and academic year (Gottlieb et al., 2020; Ikbaal & Salim Musa, 2018; Qureshi et al., 2017).

The evidence indicates that medical students experienced moderated-to-strong IS (Levant et al., 2020), which has psychological and academic consequences (Ikbaal & Salim Musa, 2018; Qureshi et al., 2017; Villwock et al., 2016). The move to the clinical phases of study can be particularly challenging and cause students to suffer from low confidence during this time (Burstein et al., 1980; Niemi & Vainiomäki, 2006). In addition, many studies confirmed that IS often negatively affects medical students’ physical and academic well-being (Ikbaal & Salim Musa, 2018; Levant et al., 2020; Villwock et al., 2016). Thus, they may miss out on opportunities because they do not recognize their potential.

There have been many studies on IS among medical students conducted across the world. However, no study has yet been published on IS among medical students in Bangladesh. Therefore, this study aims to draw attention to the growing need for more mental health research within Bangladesh. The current study focused on evaluating the prevalence of IS, exploring the frequency distribution of IS in different institutions, and assessing the factors contributing to IS among public and private medical college students. The survey provides insight into areas of commonality and differences between IS in students.

Methods

Measures

Results

We selected 500 students among the medical colleges, and the questionnaires were collected from each individual during face-to-face meetings. Therefore, the response rate was 100%. Out of the 500 participants, 233 (46.6%) were public, and 267 (53.4%) were private medical college students. Detailed information on how respondents addressed all eight questions (Villwock et al., 2016) is displayed in Table 1.

The students who answered “Yes” for five or more out of eight questions were considered positive for IS. In total, 61 (32.2%) out of 500 students answered “Yes” for five or more questions, and 339 (67.8%) answered “No” according to the definition of the YIS scale. A breakdown of YIS scores in relation to the institution is given in Table 2.

Discussion

IS affects medical students from all different medical colleges and circumstances. In this study, we found nearly one-third (32.2%) of the respondents have IS, 85 out of 184 were male, and 76 out of 155 were female students. Whereas, in a study conducted by Qureshi et al., in 2017 in Pakistan, almost half (47.5%) of the participants had IS, among 143 students where 23 were males, and 45 were females (Qureshi et al., 2017). Generally, female students were more likely to had IS. In some research, women were twice as likely to suffer from it than men (Farzana et al., 2017; Maqsood et al., 2018; Qureshi et al., 2017). Our observations were also similar, and the female respondents had more IS (32.9%) than males (31.6%). The leading cause was that women tended to address IS by confronting their concerns and working harder to address the concerns, whereas men tended to avoid areas where they felt uneasy (Villwock et al., 2016).

According to our study, fourth-year students were more likely to suffer from IS, with 39.7% meeting the criteria, the largest among all academic years. Most likely, fourth-year students faced more pressure than others because of the increased academic curriculum, worries about study and performance, and concerns about the future (Farzana et al., 2017; Villwock et al., 2016). A prior study of IS conducted in 2017 showed that among Pakistani medical college students, 23.1% of respondents had an IS score of 1 (IS score <5 means does not possess IS, ≥5 means they might possess IS), with males making up 27.1%, and females 20.2%. In the same study, 4.9% of all the students had an IS score of 4, among which 5.1% were male, and 4.8% were female (Qureshi et al., 2017). Similarly, in our study, the most frequented IS score was 4, with 30.8% of respondents scoring 4. Of those participants, 27.9% were public, and 33.3% were private medical college students. Only 0.8% of students scored 8 (meaning they might possess IS), with 0.9% from public and 0.7% from private medical schools.

According to Eva et al., private medical college students were more relaxed and confident than public medical college students (Eva et al., 2015). However, our study suggested that both public and private medical college students lacked confidence and suffered from IS. Indeed, in our study, 60.7% of private and 52.4% of public medical college students answered “yes” to the question “Do you live in fear of being found out, discovered, or un-masked?”.

An earlier study conducted in the U.S. in 2016 showed that almost 25% of male and nearly 50% of female students analysed had IS and that IS was significantly associated with burnout or dropout (Villwock et al., 2016). Every year, many students drop out or burn out and suffer from anxiety and other psychological problems (Eva et al., 2015).

According to the findings of Maqsood et al. (2018) the fourth-year medical students suffered more severely with IS than others, reflecting our own findings. They also found that 27.41% of the third year and 46.31% of fourth-year medical students had moderate IS and that 64.51% of the third year and 47.36% of fourth-year students had severe IS (Maqsood et al., 2018). In 2003, a survey of the mental health of medical students in Iran examined the age and health status of the respondents and using the 12-item General Health Questionnaire (GHQ-12) (Montazeri et al., 2003), 30.6% of first-year and 30.6% of fourth-year medical students were suffering psychological distress (Hendriksen, 2015).

A study conducted in 2012 among medical college students in Malaysia observed that 14.8% of total students were underweight (12.2% males and 17.0% females), 14.8% were overweight (males 13.7% and females 15.7%), 15.9% were pre-obese (BMI>30kg/m^2) (18.3% of males and 13.8% of females), and 5.2% were found to be obese (males 9.2% and 1.9% females) (Hameed et al., 2019). Our study has identified similar findings; 5.2% of total respondents were underweight ($\mathit{BMI}<18.5\mathrm{kg}/{\mathrm{m}}^2$), 38.2% were normal weight ($\mathit{BMI}=18.5-24.9\mathrm{kg}/{\mathrm{m}}^2$), overweight and pre-obese made up 31.8% ($\mathit{BMI}=25-29.9\mathrm{kg}/{\mathrm{m}}^2)$ and 24.8% were found to be obese ($\mathit{BMI}=30\&>30\mathrm{kg}/{\mathrm{m}}^2$). We also noticed that 38.5% of total underweight students had a positive IS score (IS score $\ge$ 5), the largest among the different BMI classes. In contrast, only 23.4% of total obese students had IS.

The generalisability of our findings on IS among medical college students studying in Dhaka, to other city students is unknown. Studying only medical college students in Dhaka, may have resulted in an underestimation of the coverage of IS. Similarly, investigating the underlying causes was beyond the scope of our study. Our study presents the risk of IS at the time of our assessment, however, the situation in Bangladesh has likely further deteriorated because of the COVID-19 pandemic. Given that the COVID-19 situation has forced Bangladesh’s education system to close for nearly two years, there is a greater need that ever to conduct surveys to monitor mental health issues such as IS amongst students. Our presented data and our risk analysis showed higher BMI, and higher MFI coincided with lower risk of IS. So, ensuring appropriate diet and proper socio-economic improvement, may help reduce the risk of IS and other mental health problems among medical students. The hope is that this study will encourage more research on this topic and a greater understanding of the impact of IS on various aspects of the social, academic, and daily life of those who suffer from it.

Strength and limitations

This study advances knowledge in several ways. This research is among the first to examine the risk of IS among medical college students in Bangladesh, which is not a commonly discussed syndrome within this country. This research also addresses further need for inquiries into the psychological predictors of IS, helping to understand the reasons and the causes behind IS. IS is an increasingly prevalent psychological syndrome. However, it’s possible, when looking for participants for a mental health study, potential volunteers might be hesitant to participate due to the personal nature of the topic. As a result, snowball sampling was utilized in this study to reach the population, because it is difficult to collect samples using other sampling methods.

While this study makes several contributions to IS research, there are some limitations. This study used the snowball sampling method, which is a non-probability type sampling method. The researchers had little control over the sampling approach. We only interviewed those who were recommended by the previous respondents. Therefore, the sampling approach was limited and subjective. There might be some sampling bias present in this study because of the nature of the sampling method. Because of the sampling bias, our samples might not represent the true distribution of the population. Similarly, our study only sampled Dhaka city; it would’ve been better if we’d studied the entire country. Consequently, we would have been able to get a better picture of the distribution of IS and the underlying factors that influence it.

Conclusion

Our analysis revealed a serious public health issue for medical college students in Bangladesh. As a result, students may suffer from depression and, in some cases, even commit suicide (Qureshi et al., 2017). Public and private medical institutions should take that matter seriously and establish various programs, organizations, counseling teams, and other activities to help identify students suffering from IS and support them. It is evident that students, especially those in their third and fourth year of medical college, need more care than others to ensure they stay focused on their goals. Faculty and fellow students should guide, mentor, and encourage IS suffers to produce self-confident and self-sufficient students.

Data availability