1 INTRODUCTION

Imposter phenomenon (IP), or perceived fraudulence, describes an ongoing fear of exposure as a fraud or imposter, despite objective successes and accomplishments.¹ Those with IP tend to attribute their achievements to luck or good timing and question their professional legitimacy and expertise.

A 2020 systematic review² outlined the prevalence, predictors, and potential treatment of this long-recognized phenomenon that impacts approximately 70% of working professionals at some point in their career. IP was strongly correlated with depression and anxiety, poor work performance, job dissatisfaction, and burnout, particularly among ethnic minority groups.² Their findings suggested those affected may be limited in achieving their full professional potential and are more likely to experience burnout and a decline in psychological well-being.

Healthcare professionals are prone to experiencing IP due to the demanding nature of their work. The combination of high care standards, long working hours, continuous learning expectations, and emotional stress of dealing with challenging situations creates a constant pressure to excel and fear of falling short. One in four physicians reported frequent or intense IP.³ Poor mental health, higher level of burnout, and lower job satisfaction have been cross-sectionally linked to greater IP among medical students and practitioners.^{3, 4} However, the role of sex, gender, and years of work experience remains inconclusive.^3-8

Despite the growing interest of IP in medicine, IP in the physical therapy profession has been scantly examined. The prevalence of IP was 35% in a sample of 200 physiotherapists in India.⁵ Among 106 physical therapy students in Slovenia, 38% had frequent or intense IP.⁶ More advanced age, greater years of study, and having clinical work experience appeared to be associated with lower IP in these students,⁶ although no multivariable analysis was conducted to control for the effects of other factors.

Professional burnout and mental health comorbidities are on a steep rise, further fueled by the recent Covid-19 pandemic.⁹ While job burnout among physical therapists (PTs) is associated with emotional exhaustion and a decreased sense of personal achievement,¹⁰ no study has examined the prevalence of IP in licensed PTs in the United States and explored whether it is linked to burnout and job satisfaction. The objectives of the present study were to (1) examine the prevalence of IP among licensed PTs in the United States, (2) determine demographic and professional factors associated with IP, and (3) examine its relationship with burnout and job satisfaction.

2 METHODS

3 RESULTS/FINDINGS

A total of 520 survey responses were recorded. After excluding responses from physical therapy students and/or physical therapy assistants (n = 5) and the response without any demographic data (n = 1), our final analysis sample consisted of 514 records.

Table 1 summarizes the demographic and professional characteristics of the study respondents. The majority of respondents were women (66.1%), at or under 40 years of age (73.2%), and White race (77.0%). The mean IP score was 60.3 (SD: 15.1, range: 19–95). As shown in Figure 1, 55 (10.7%) had low IP, 196 (38.1%) had moderate IP, 215 (41.8%) had frequent IP, and 48 (9.3%) had intense IP. When dichotomized, IP was absent in 251 (48.8%) and present in 263 (51.2%) survey respondents. A sensitivity analysis to compare 4-level versus 2-level IP categories showed immaterial differences in factors with a p ≤ 0.20 (see Supporting Information S1: Table 1).

Age was strongly correlated with years of experience as a PT (R = 0.85), therefore was excluded from the model to avoid multicollinearity. The initial logistic regression model included the following 11 predictors: gender, geographic location, time as a licensed PT, time in current position, terminal degree, manager/supervisor experience, time spent on direct patient care, time spent with patients during initial evaluations, history of or current mental health diagnosis, emotional exhaustion, and job satisfaction.

Following the principles for purposeful model selection (outlined in the Methods section), we identified the final most parsimonious logistic regression model, shown in Table 2. The Hosmer–Lemeshow goodness-of-fit test had a p = 0.897, suggesting that there was no significant difference between observed and predicted values.

Having managerial or supervisory experience reduced the likelihood of IP by 45% (OR = 0.55, [95% CI = 0.34–0.90]). Having a terminal bachelor's or master's degree (vs. a terminal DPT degree) (OR = 2.31, [95% CI = 1.07–5.00]); history of or current mental health diagnosis (OR = 2.77 [95% CI: 1.69–4.54]), unsure/undiagnosed mental health diagnosis (OR = 3.21 [95% CI: 1.74–5.94]), and moderate or high level of emotional exhaustion (OR = 5.37 [95% CI: 2.11–13.69]; OR = 14.13 [95% CI: 5.56–35.89], respectively] each increased the odds of IP. Having 11–20 years of clinical experience (vs. ≤5 years) and holding their current position >6 years (vs. <1 year) may reduce the odds of IP (OR = 0.55 [95% CI: 0.28–1.08, p = 0.08]; OR = 0.50 [95% CI: 0.24–1.04, p = 0.06], respectively). It is important to point out that these associations were cross-sectional; no causal inference could be made. For example, the negative association of having managerial or supervisory experience and the presence of IP could be bidirectional. Those with IP might not believe that they could be in a leadership role, therefore may not seek a managerial/supervisory position; or managers/supervisors were less likely to experience IP.

4 DISCUSSION

IP is highly prevalent among PTs in the United States. Over half of the survey respondents reported frequent or intense IP. Seasoned clinicians holding managerial positions exhibited a lower susceptibility to IP, whereas individuals with a mental health diagnosis, emotional exhaustion, and lacking a DPT degree were more prone to this phenomenon. Other factors, such as gender, race, sexuality, geographic location, practice specialty/setting, APTA membership, and job satisfaction did not significantly influence IP. A reduced likelihood of experiencing IP appeared to be associated with a greater length of time held in a professional position. Interestingly, there appeared to be a sweet spot in terms of years as a licensed PT. Specifically, having 11–20 years of clinical practice experience may be linked to reduced IP. To the best of our knowledge, this is the first report investigating the prevalence, predictors, and impact of IP among licensed PTs in the United States. Given the high prevalence of IP and its potential negative impacts on mental well-being, it is important to provide education and resources to effectively manage and overcome this phenomenon in the physical therapy community.

The current study findings are in general agreement with previous research conducted in other licensed healthcare professions. In a literature review of studies involving medical students, residents, and physicians,⁴ the prevalence of IP ranged from 22.5% to 46.6%. The mean imposter scores within these studies ranged from 47.0 to 61.2. Frequent-to-intense IP was observed in 38.9% of neurosurgeons and neurosurgery residents, with the majority of individuals reporting moderate levels of IP (42.7%).²⁰ A significant proportion of radiologists (71%) experienced frequent-to-intense IP.²¹ This finding should be interpreted with caution. The limited number of participants (n = 21) may introduce the possibility of participation bias, which could potentially overestimate the rate of IP. It is unknown whether the extent of IP differs in various healthcare providers. To our knowledge, no study has directly compared IP prevalence across different healthcare professionals.

A noteworthy result emerged from the current study, revealing that over 40% of respondents reported a diagnosed or suspected mental health condition. This finding underscores the significance of pre-existing mental health comorbidities in PTs. These conditions can be further exacerbated by elevated levels of occupational stress resulting from a number of factors, including demanding physical and mental workloads, significant administrative work (e.g., documentation and billing), high patient expectation and demands, the constant pressure to stay updated in the field and continually learn, and productivity benchmarks within healthcare settings.^{10, 22, 23} Our data showed that respondents with diagnosed or suspected mental health conditions were approximately three times more likely to experience IP. Poor mental health can significantly hinder professional performance, elevate the risk of medical errors, contribute to burnout, and amplify the experience of IP.^{3, 4, 24} Further, individuals with perfectionist tendencies and difficulty internalizing their successes are more susceptible to experiencing IP. These tendencies not only contribute to the development of IP but can also function as precursors to mental health conditions, such as anxiety and depression. This interplay between perfectionism, inadequate self-assessment of achievements, IP, and mental health challenges could have detrimental effects on professional and personal outcomes.^{3, 4, 22, 24}

The majority of PTs (87.7%) in this survey experienced at least moderate levels of emotional exhaustion and approximately half experienced high levels. Emotional exhaustion has been identified as a central measure of burnout,^{25, 26} which could lead to medical errors, reduced productivity, and turnover.^{10, 23} Contrary to a previous study that reported no clear relationship between burnout and IP in 48 internal medicine residents,²⁷ we found a dose–response relationship between emotional exhaustion. A higher level of emotional exhaustion was associated with a greater likelihood of IP. PTs may be more susceptible to burnout, given the prolonged and frequent patient encounters within a typical work week.¹⁰ However, in our study sample, reported job satisfaction was high among PTs (82%). Time spent on direct patient care or time spent with patients during initial evaluation and return visits did not appear to heavily impact IP. Thus, factors beyond workload and time spent with patients must be further explored to better understand the underlying causes for emotional exhaustion in PTs.

Respondents with managerial/supervisory roles or longer time in the current position were less likely to experience IP. Prior research has not consistently demonstrated a clear relationship between job ranks or professional longevity with IP. Among surgeons, IP was more prevalent and worse in trainees and residents than faculty mentors.^{20, 28} On the contrary, nontenured faculty had lower IP scores than their tenure-track counterparts²⁹ and IP was common in those working in top research institutions.³⁰ This is potentially due to the high-pressure research environments and intense competition for funding and recognition. The conflicting observations could be related to differences in job security, workload, and expectations between clinical and academic settings.

Gender was not linked to IP when accounting for other demographic, professional, and mental health factors. While early studies primarily focused on the prevalence of IP in females in various occupational settings, updated research revealed that IP is common in both men and women.² Notably, the univariable association between gender and IP attenuated to non-significance after adjusting for other variables. This finding highlights that gender alone may not be a significant predictor of IP and caution against drawing conclusions solely on gender when seeking to understand the risk profile of IP.

The present study has significant strengths. This is the first study that comprehensively examined IP and its predictors among licensed PTs, using a widely accepted, validated outcome measure to categorize IP. Compared to previous research of IP in healthcare professionals, the present study included the largest sample to date and employed a more rigorous analytic approach of multivariable regression modeling that encompasses a broad spectrum of demographic and professional factors. Our study sample was representative of the demographics of licensed PTs in the United States, as reported by the US Bureau of Labor Statistics, 2022.³¹ This alignment with the broader PT community enhances the generalizability of our findings and allows for meaningful comparisons and inferences regarding IP in PTs. Additionally, a focus group was utilized before survey distribution to ensure inclusivity and ease with the survey experience.

Our study also has limitations. The cross-sectional study design precludes us from establishing causal relationships. We cannot definitively determine whether the identified demographic and professional factors were predictors for or consequences of IP. Nonetheless, this study provides a valuable framework for future investigations aimed at mitigating potential risk factors associated with IP. Future longitudinal studies could provide a more in-depth understanding of the dynamics over time and allow for the examination of causal relations. An online survey study design has some inherent limitations. The decision of invited survey participants to respond or not could be influenced by their level of interest in the topic or their availability at the time of the survey invitation, potentially introducing bias to the sample. Additionally, self-reported data may be influenced by factors like social desirability and recall bias. Although this survey was peer reviewed by a focus group of PTs from diverse clinical settings to ensure clarity and comprehensibility before its dissemination, some variability in the interpretation of the survey questions may have occurred. Due to the multiple channels of survey distribution and deidentified collection of information, individuals may have accessed and responded to the survey more than once, despite being informed to avoid repeated attempts.

IP is highly prevalent among licensed PTs, with more than half reporting frequent or intense IP. Seasoned clinicians with managerial roles seemed to be less susceptible to IP, whereas those with mental health diagnoses, emotional exhaustion, and those without a DPT degree may be more likely to experience IP. Given the high prevalence of IP and its negative impacts, it is important to prioritize education and awareness about this phenomenon. PT clinicians and students need to be equipped with information, strategies, and resources to effectively manage and mitigate IP, ensuring their long-term professional success and personal well-being.

AUTHOR CONTRIBUTIONS

Alexandra R. Anderson: Conceptualization; data curation; investigation; methodology; project administration; writing—original draft; writing—review and editing. Jamie LaPenna: Conceptualization; investigation; methodology; project administration; writing—original draft; writing—review and editing. Dustin Willis: Data curation; investigation; methodology; project administration; writing—original draft; writing—review and editing. Khyrah Simpson: Data curation; formal analysis. Alison H. Chang: Data curation; formal analysis; methodology; writing—original draft; writing—review and editing.

CONFLICT OF INTEREST STATEMENT

The authors declare no conflict of interest.

ETHICS STATEMENT

Study approved by West Coast University's Institutional Research Board. Each participant provided informed consent before taking the survey.

TRANSPARENCY STATEMENT

The lead author Alexandra R. Anderson affirms that this manuscript is an honest, accurate, and transparent account of the study being reported; that no important aspects of the study have been omitted; and that any discrepancies from the study as planned (and, if relevant, registered) have been explained.