Why So Many Doctors Lack Self-confidence, and How to Get It Back
Pamela L. Wible, MD
I’ve often heard patients describe doctors as arrogant, but never lacking self-confidence. Yet, like all people, doctors have self-doubts. How do physicians cope with their insecurities? Do doctors need more self-confidence?
To the observer, most physicians appear self-assured. In fact, some patients say that doctors seem overly confident, even cocky. Nobody wants an insecure physician; a confident doctor inspires confidence in patients.
I discovered that physicians lack self-confidence when I began leading business courses for doctors. As a physician-entrepreneur, I teach colleagues the business strategies to succeed in independent practices. For 10 years I’ve been asking physicians what they would like to learn most from me. Self-confidence always ranks near the top. The response:
- “I need renewed confidence that I am intelligent and that I can achieve my goals.”
- “I need confidence personally, professionally, and in my future. I want to overcome my fear of embarking on this project.”
- “I want my confidence back. Right now I don’t know what to think. I feel like I’ve been second-guessed at every turn by administrators, ‘evidence-based medicine,’ peer reviews, and patients. I’m beaten down.”
The Truth About Physician Self-confidence
We enter medical school with our mental health on par with or greater than that of our peers. We’re top of the class—even valedictorians. We’ve got confidence. So what happens? To investigate, I surveyed 189 medical students. I asked them to answer one multiple-choice question: “How has medical school impacted your overall self-confidence and/or self-esteem?” Of the respondents, 42% reported an increase, 50% reported a decrease, and 8% noted no change. Medical students were then encouraged to share why.
“Definitely increased it,” reports Lisa. “How can it not? All of this new information and knowledge and skill. Every day I make a million mistakes, but I also learn so much. The senior residents ‘pimp’ but you accept it for what it is—it has zero impact on who you are as a person.”
“Increased it,” echoes Suzanne. “Blame this joy on the amazing physicians and professors at my medical school!”
But many more students shared how training shattered their self-worth. “Med school completely destroyed my self-confidence,” Lynn writes. “I am constantly feeling stupid and worried about failing out.”
“Probably decreased overall, especially at the hospital,” reveals Andrea. “Not knowing what I’m doing. Patients not wanting me in the room. Attendings telling me to get out of the way. Residents telling me not to ask so many questions. And I’ve only been here a month!”
The most disturbing report comes from Claire: “I imagine all med schools are difficult, but mine is sadistic (a direct quote from our school counselor). My school is notorious for failing students—10%-20% of every class every semester. It doesn’t matter if your brother just died; if you’re .01% away from passing any class, you’re dismissed. No makeup tests. Before med school, I was a 3.98 student. Today I’m a C+. Talk about deflating. I’ve gone to every department to figure out how to bring my grades up, but the response is, ‘You’re not smart enough.’ I know that’s not true, but it hurts that my school doesn’t think I belong here (but they’re happy to take my money). All this crap has culminated in a deep depression. I’ve developed test anxiety that paralyzes me during exams. The only help I’ve received is antidepressants. I constantly doubt myself. I even struggle to interact with my husband and son. I feel like an idiot for coming here—and even worse for dragging my family into this $200,000 mess without knowing if I’ll ever pay it off. I worry that I’ll never be able to practice medicine. It’s enough to drive anyone mad. Worst of all, I’ve become cocky just to deal with all the assholes that I’m surrounded by, but my confidence is down the toilet.”
Of those who reported no change in self-confidence, most had just started their first year. More common is a pattern of self-confidence being “destroyed in the didactic years” and “built back up in the clinical years,” as reported by Oliver: “Medical school locked me in a study dungeon. I floundered, fell further behind, and felt intimidated to ask for help. I had gone from the top 10% at my undergrad to the bottom and felt completely helpless. One professor suggested I wouldn’t make it as a doctor. The school provided CYA-type meetings but didn’t give actual help. Then I excelled in clinical rotations. I’m back in control of my world. If I continue on this trajectory, I’ll be more confident than ever, but that’s because I survived nearly being destroyed. The system isn’t set up to make you feel good about yourself, and some of my classmates are coming out ready to pay their debts and then retire from medicine.”
Post-traumatic Student Disorder?
What are the long-term effects of medical training on physician self-confidence? I surveyed 1123 physicians with the multiple-choice question “How did medical school and residency impact your overall self-confidence and/or self-esteem?” Of those who responded, 46% reported an increase, 46% reported a decrease, and 8% noted no change. Physicians who responded were encouraged to share why. Of those who reported a decrease, their experiences often led to chronic mental health issues, including PTSD.
“I was near death when I departed my residency. I’ve personally known three very compassionate, competent residents who took their own lives while mired in their darkness and disillusion during my training. Medical school was a devastation in my life and forever changed not only my career path, but also my personal health, relationships, and my perspective on the medical field,” reports Laurel, who is no longer practicing medicine.
Abusive preceptors who used fear-based teaching often undermined students’ education. Renee, an obstetrician, shares, “It would be many years before I recovered from the fear of what was the motive behind a question. The sad thing is that I now realize most people are not coming at you in attack mode, and I had missed out on a lot of opportunities. However, most of my colleagues, it seems to me, have never recovered. Physicians do not befriend one another. They are either arrogant and don’t need friends, or distrusting and will never let you in.”
Many female physicians also survived sexual harassment. Steve, an internist, confirms, “My residency director wanted me to wash out—or commit suicide—so it wasn’t a big confidence-builder. He liked to destroy people. He used to punish females who wouldn’t put out—medical school or residency, married or single. For us males, it wasn’t that bad.”
“I entered medical school so very confident in myself and that was beaten out of me,” confirms Amelia, who is now applying to residency. “I was repeatedly told I was stupid. I was threatened with being sent away from my 6-month-old without warning for the sake of medical school. Motherhood was not supposed to be a priority. I was labeled ‘too emotional’ as I burst into tears after being bullied. I begged for help with my anxiety and was flatly denied any assistance.”
“Our program director suggested we get slave T-shirts for the group,” said Melissa, an internist, “In my residency mailbox I even received nasty anonymous ‘you’re too fat’ notes, with ads for diet pills attached.”
“I had emotional whiplash in residency,” reports Rochelle, a solo family physician. “Attendings would gang up on one resident and say, ‘You’re destined to fail. You’re lazy.’ I received scathing reviews about ‘attitude’ and ‘difficulty with authority.’ I remember standing in my bedroom having these crazy panic attacks and thinking I could not go on. They stopped picking on me after a few months and picked on someone else, but I’d see it and it would make me sick. I personally know of one resident in every class who became suicidal while I was there. One had a car ‘accident’ and died going off a cliff but we all wondered if that was actually an accident.”
“Medical school/residency took my self-confidence and self-esteem from poor to suicidal,” claims Karen, an emergency medicine physician. “I’m not worth the air I breathe. Starting to practice brought me back up to poor self-confidence and poor self-esteem. Recently, with counseling, I’ve got pretty good self-confidence and decent self-esteem.”
“I was published and academia-bound when I started medical school,” says Linda, another emergency medicine physician. “I encountered quite a few prejudiced, sexist, and terribly ignorant people. One day I challenged a male student regarding his response to a question and he literally lunged over a table whilst threatening me. A number of male surgical types sought to put me in my place, especially if I failed to be deferential. I spent a lot of time in tears and horribly lonely. It took years to rebuild my self-esteem, but due to the long hours I’ve continued to struggle with loneliness. My marriage broke down and we didn’t have any kids.”
Medicine often endorses a culture of groupthink that discourages dissent, discussion, and individuality. Jenny, an internist, recalls, “The further I progressed in my training, despite acquisition of more skills and knowledge, the more fearful I became. Criticism in various forms never ended. The further my confidence dwindled and I became more outwardly hesitant (despite feeling inwardly confident about my answer or plan), the more colleagues questioned my decisions. This may have to do with my almost extreme introversion and difficulty asserting myself. I watched colleagues often act and speak very confidently even when I knew they didn’t totally know what they were talking about. I never mastered this skill of acting confident even when in doubt. I felt it was disingenuous. My true opinions on what was best for a patient were frequently different from the group’s. I became afraid of expressing myself, even when I knew I was absolutely correct. Before medical school I was never afraid to be a dissenting voice, but I learned in residency that it did not matter if I was correct—disagreeing with someone higher up than myself, even if in the interest of patient safety, was not in my best interest.”
Ann, a neurologist, summarizes, “One needs a trust fund of self-esteem in order to survive medical school and residency.”
Self-confidence Success Stories
For every physician who reports a decline in self-esteem and/or self-confidence in medical training, another reports an increase. What’s the secret to thriving in medical school? Just getting into medical school is a confidence builder. After graduating med school, many physicians feel they can survive anything.
Physicians fared best in progressive schools that promoted student well-being and medical humanities. Some doctors strategically avoided certain specialties. “I had a sense of self-preservation and avoided the specialties where I observed residents being routinely abused and dehumanized,” Wayne shares. “I was attracted to psychiatry by the attending staff that exhibited a more holistic and gentle approach to patient care. I escaped residency unscathed emotionally and gained a lot of insight into my own blind spots. My self-esteem and confidence were certainly bolstered by my medical training.”
Having a good support system strengthens students’ self-worth. “I had a great core group of friends in my residency and a very supportive group of attending physicians. We helped each other and always made time for fun,” shares Paul, an internist.
A welcoming atmosphere of mutual respect and open communication positively affects self-worth. “My medical school was wonderful,” Rochelle says. “We were called ‘young doctors’ and generally allowed to question things. We were encouraged to report harassment and they told us, ‘You are all the brightest and the best and you are going to go on to amazing things.'”
Linda, a family physician, reports, “I think self-esteem is a more fundamental issue that is pretty set once you’ve reached med school and residency. My self-esteem is generally good, which is why I refuse to put up with this abusive medical system. I don’t let other people abuse me and I won’t allow this broken system to abuse me either.”
Practice Makes Perfect: Physicians Find Themselves
I surveyed the same 1123 physicians with a second multiple-choice question: “How has practicing medicine impacted your overall self-confidence and/or self-esteem?” Of those who responded, 47% reported an increase, 37% reported a decrease, and 16% noted no change. All were encouraged to share why.
While physicians may feel insecure early in their careers, treating patients independently builds confidence. The profession of medicine is an incredibly rewarding experience for most. Physicians tend to feel happiest in the positive relationships they build with patients and colleagues. “I love caring for patients. Nothing comes remotely close as a vocation,” writes Elias, a hematologic oncologist. “Mentoring is a big part of who I am and I have been privileged to have mentees who still turn to me for advice (personal and professional) long after they moved on. I am indeed a caregiver.” Doctor means teacher and the best physicians are lifetime learners and teachers.
“I’ve practiced in small communities where I’m able to see the impact of my work,” says Paul, an internist. “I’ve been fortunate to have good colleagues and staff. Of course, it’s not all roses and chocolate; there are days I want to walk away from it all. But I’ve made a conscious effort to cultivate compassion and equanimity to deal with frustrations. The only time my core self-esteem was threatened was when I was sued for malpractice. But I had a great legal team and we successfully defended the case in front of a jury. So, in the end, even that negative experience helped to bolster my self-esteem.”
A Self-esteem Roller Coaster
A positive employment experience can help physicians who have lost self-esteem during medical training. “When I got my first job out of residency, I was so timid,” says Rochelle, a solo family physician. “Every time one of the physicians who owned the practice would talk to me, I would just about jump out of my skin thinking they were going to berate me. One morning the medical director told me he wanted to talk with me during lunch. I was frantic. I could barely breathe when I went to his office at lunch. Do you know what he said? ‘I just wanted to let you know that we’re all really glad that you’re here. We’re really impressed with your work. I hope someday you’ll consider buying in to the practice.’
“I walked away in shock,” Rochelle said. “That was when I realized how damaged I’d been during residency. That practice was where I did my initial healing, learning to trust myself and other doctors again. The broken medical system eventually became too much for me and I decided to open my own practice to provide care for the uninsured and underinsured, and now I feel even better.”
Still, some physicians feel that practicing medicine is a self-esteem roller coaster. “My self-esteem depends on the day and time,” says Alison, a pediatric neurologist. “There are days when you get a rare diagnosis right and make such a huge difference in a patient’s life which makes your self-worth soar. Other days your hospital tells you that you don’t see enough patients, bill enough RVUs, and you just can’t make that one patient happy which makes your self-esteem plummet.”
After Medical School and Residency: Physician Self-destruction
After all of the education and time invested in medicine, many physicians continue to feel injured by the healthcare system. The list of assaults on the physician psyche in modern medical practice is beyond the scope of this article. A great many physicians do suffer, often in isolation, throughout their careers.
Retaliatory culture and institutional bureaucracy shatter physician self-confidence. David, a family physician shares, “I definitely experienced PTSD from medical training and continue to do so periodically from the daily practice of medicine.” Others are equally exasperated. “Practice kicked my ass,” says Mark, a neurologist. “The demands of insurers, workers’ comp, paperwork that did not exist during training, were inescapable and soul-sucking. The call demands were unexpectedly way increased because of hospital policies. For the most part, caring for patients was a refreshing escape and why I went into medicine.”
But some patients are not a refreshing escape. “I questioned myself constantly,” reveals Yvonne. “I practiced in Manhattan where patients come in to the office already knowing your background and how they think you should treat them. They’re incredibly informed and have an ophthalmology friend who second-guesses what you do. The expectation of patients is very high and there’s a lot of pressure to meet their expectations in order to compete with the dozen ophthalmologists who work within a few square blocks of you.”
“Practice clearly ruined my life and my self-confidence and self-esteem,” reports Peter. “As a psychiatrist I was cut out, carved out, and devalued. I overworked and ruined my personal life. Sad. I take responsibility for allowing Medicare, insurance companies, administrators, and patients to take advantage of my fine personality traits and professional skills. I needed role models but they were just as overwhelmed. Professional organizations abandoned us and sat quietly, watching passively as physicians were groveling. Unacceptable. They all should be fired.”
“Residency was bad, fellowship was worse, and now at the age of 56 years, I have to keep reminding myself why I am alive,” says Michelle, a pediatrician. “I have never felt more worthless in my life. I calculated my hours and realized that I could work 3 jobs: Panera baker, Chick-Fil-A, and house cleaning, and make as much money working as many hours…and would potentially have better self-esteem.”
Melissa, an internist, concludes: “I feel like I’ve completely wasted my life. Many personal sacrifices to become a physician. Nothing to show for it.”
How to Change This Phenomenon
Though many medical students and physicians experience enhanced self-confidence and/or self-esteem, our medical education system injures nearly half of our nation’s medical students and physicians—many with lifelong sequelae. From my own research, 38% of practicing physicians report that working in the American healthcare system has harmed their self-confidence. Here’s how doctors can protect themselves and their colleagues and help the next generation of physicians.
- Stop institutional abuse. Sexism, racism, and bullying should be never-events in our healthcare facilities. Witness abuse? Report it. Stand up for yourself, your colleagues, and patients. Ban fear-based teaching methods. Remove abusive professors from teaching positions and offer remediation. Medical students should be protected, not injured, by our healthcare institutions.
- Seek mental health care. All medical facilities should have on-site mental health services for health professionals. Medical students and physicians shouldn’t be punished for seeking healthcare. Doctors should be encouraged to grieve and offered a safe place to do so at work. We must receive the care we are expected to provide to our patients.
- Build strong relationships. Maintain supportive relationships with friends and family. Befriend physicians. Be a mentor. Remember: The foundation of healthcare is the sacred patient-physician relationship.
- Promote a culture of open communication and respect. Vulnerability and authenticity should be welcomed in medicine. Encourage open discussion, self-doubt, and self-discovery. Honor individuality. Respect each other. Nurture medical students. Inspire them to remain in medicine, stay alive, and live with empowerment and purpose.
- Refuse to be a victim. Although my medical training was dehumanizing and I was undervalued by my employers, my self-confidence ultimately increased in both medical school and in the practice of medicine. Surviving the inhumanity strengthened me. Not everyone survives. But I prevailed because I refused to be a victim. I encourage my peers to do the same.
Pamela Wible, MD, pioneered the first Ideal Clinic designed by patients. When not treating patients, she hosts physician retreats to help doctors launch independent practices and recover from the trauma of their training.
View the original post here.