Challenges in the transition to independent dermatology practice: prevalence of impostor phenomenon and a needs assessment of professional skills

What is known about this subject in regard to women and their families? Studies have shown that female physicians are at particular risk of impostor phenomenon during the transition from trainee to independent practice, and that early physicians are not confident in the managerial skills required to run a successful independent practice. What is new from this article as messages for women and their families? This study reveals that female dermatology residency graduates are at significantly higher risk of impostor phenomenon compared with their male counterparts. Designing a curriculum to address the professional skills identified as important in this study—business management, emotional intelligence, communication and negotiation, financial accounting, and leadership—may build confidence among dermatologists transitioning into independent practice. Physicians face a multitude of challenges in the transition from trainee to independent practice. Studies have shown that female physicians are at particular risk of impostor phenomenon (IP) during this transition, and that early physicians are not confident in the managerial skills required to run a successful independent practice.1–3 Previous research on gender differences in IP among physicians is mixed, with some studies finding higher rates in women while others report no difference.4 Few studies on this transition have been conducted in dermatology. We developed a needs assessment survey for recent dermatology residency graduates to assess their experiences with IP using the Clance Impostor Phenomenon Scale (CIPS), their perceived importance of professional skills, and their confidence in performing these skills during the transition to independent practice. We sent an anonymous online survey to graduates of the University of Utah, University of Washington, and Yale dermatology residency programs from 2014 to 2024. Statistical analysis was performed with SPSS, version 29 (IBM Corporation) using the unpaired t test for continuous variables and Pearson’s correlation coefficient, with 2-tailed significance defined as P < .05. Of 121 graduates, 41 (33.9%) completed the survey with an average age of 38.4 years (range, 31-56 years) and a female predominance (63.4% female). Respondent demographics by gender are summarized in Table 1. The mean CIPS score was 61.1, indicating significant impostorism. The mean scores of female and male participants were 64.5 (15.8) and 53.4 (10.0), respectively. This difference in mean CIPS score by gender was statistically significant (P = .02), with an effect size of 0.8 according to Cohen’s d, indicating a large effect. Years in practice were not significantly associated with the CIPS score. Professional skills highly ranked in importance included business management (60%), emotional intelligence (57%), communication and negotiation (43%), financial accounting (40%), and leadership (38%) (Table 2). However, business management was one of the professional skills that respondents reported the least confidence in at graduation, along with financial management and financial accounting. For e-learning modalities, podcasts were the preferred medium (57%), followed by video lectures (50%) and scenario-based online modules (43%). Table 1 - Characteristics of survey respondents by gendera Characteristic Female (n = 26) Male (n = 14) P-value Age, years, mean ± SD 38.23 ± 5.87 38.14 ± 4.37 .96 Race, n (%) .278c White 22 (84.6%) 14 (100.0%) Non-Whiteb 4 (15.4%) 0 (0.0%) Years in practice, mean ± SD 4.25 ± 3.09 4.18 ± 2.71 .94 Practice setting, n (%) .185 Academic 15 (57.7%) 5 (35.7%) Nonacademicd 11 (42.3%) 9 (64.3%) Subspecialty, n (%) N/Ae Medical 23 (88.5%) 10 (71.4%) Surgical 5 (19.2%) 4 (28.6%) Pediatric 1 (3.8%) 1 (7.1%) Dermatopathology 0 (0.0%) 3 (21.4%) Other 1 (3.8%) 3 (21.4%) None 1 (3.8%) 1 (7.1%) Leadership role in practice, n (%) N/Ae Administration 9 (34.6%) 2 (14.3%) Teaching 9 (34.6%) 2 (14.3%) Research 2 (7.7%) 2 (14.3%) Other 1 (3.8%) 0 (0.0%) None 10 (38.5%) 10 (71.4%) E-learning modality preference N/Ae Podcasts 19 (73.1%) 5 (35.7%) Video lectures 14 (53.8%) 6 (42.9%) Scenario-based online modules 13 (50.0%) 4 (28.6%) Audio lectures 10 (38.5%) 4 (28.6%) Unsure 4 (15.4%) 3 (21.4%) Clance Impostor Phenomenon Scalef, mean ± SD 64.54 ± 15.84 53.36 ± 10.01 .02 SD, standard deviation.aParticipants who selected “Prefer not to say” for gender (n = 1) were excluded from sex-stratified analyses.bNon-White includes Asian (n = 3) and other (n = 1) racial categories.cChi-square test or Fisher’s exact test used for categorical variables (reporting Fisher’s exact if any expected cell count <5).dNonacademic includes private practice (n = 18) and other community-based settings, including Health Maintenance Organization and multispecialty groups (n = 2).eParticipants could select multiple responses; percentages may sum to >100%. Statistical comparison not performed.fA score of ≤40 indicates few impostor characteristics, 41-60 indicates moderate impostor experiences, 61-80 indicates frequent impostor feelings, and >80 indicates intense impostor experiences. Table 2 - Professional skills and participants’ perceived importance and confidence level Professional skill Ranked in top 3 in importance, n (%) Confidence level at time of graduation on Likert scale (1: not at all confident, 5: extremely confident), mean ± SD Business management (ie, managing ancillary staff, optimizing workflow) 25 (60) 1.98 ± 1.07 Communication and negotiation (ie, building and maintaining a referral base, negotiating contracts) 18 (43) 2.67 ± 1.05 Data analysis (ie, tracking patient outcomes, conducting research studies) 0 (0) 3.00 ± 1.25 Emotional intelligence (ie, connecting with patients, managing team dynamics) 24 (57) 4.02 ± 0.78 Financial accounting (ie, understanding clinic’s revenues, expenses, and profitability) 17 (40) 2.00 ± 1.06 Financial management (ie, investing in new equipment, understanding cash flow, and financial forecasting) 6 (14) 1.93 ± 1.16 Leadership (ie, guiding the practice’s vision, directing an interprofessional team) 16 (38) 3.17 ± 1.03 Networking (ie, building a professional network, collaborating for research) 8 (19) 3.07 ± 0.92 Project management, planning, and organization (ie, designing quality improvement initiatives, expanding a clinical practice) 8 (19) 2.98 ± 1.14 Understanding of economics (ie, pricing strategies, resource allocation) 4 (10) 2.02 ± 1.02 SD, standard deviation. This study reveals a significant difference in IP by gender, with female dermatology residency graduates at higher risk for IP as compared with their male counterparts. Our findings align with studies showing gender differences in IP,4 but contrast with a recent study that found no significant difference in dermatologists.5 However, our study is the first to assess IP among dermatologists using a validated scale. Generalizability is limited by a low response rate and a predominantly white study population. Future work should aim for higher participation. Recognizing that IP is multifactorial, we focused our needs assessment on professional skill development, addressing a gap in residency education identified in previous studies.2,3 Designing a curriculum to address the professional skills identified as important—business management, emotional intelligence, communication and negotiation, financial accounting, and leadership—may build confidence among dermatologists transitioning into independent practice. Given the increased risk of IP in female dermatologists, targeting the curriculum to this audience may be valuable. Conflicts of interest None. Funding This publication was made possible by the Arons-Millard Student Research Fund. AJL is supported by K08 AR081408 from the National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS). Study approval This study was reviewed and approved by the Yale University Institutional Review Board and classified as exempt under protocol #2000038954. Author contributions SH: Participated in research design, performance of the research, data analysis, and writing of the paper. HB: Participated in performance of the research and editing of the paper. AJL: Participated in the editing of the paper. LW: Participated in performance of the research and editing of the paper. ALD: Participated in performance of the research and the editing of the paper. CAN: Participated in research design, performance of the research, and participated in the writing and editing of the paper. Data availability The data underlying this article will be shared on reasonable request to the corresponding author. Acknowledgements The authors would like to acknowledge the faculty of the Center for Medical Education at the Yale University School of Medicine, in particular Janet Hafler, EdD and John Encandela, PhD, for providing expert guidance on medical education research methodology. Furthermore, we would like to thank Jean L. Bolognia, MD, Jeffrey Cohen, MD, MPH, Dana Dunne, MD, MHS, and Christine Ko, MD for providing specific mentorship on this study.