The Impostor Phenomenon Construct in Medical Education: A Meta-Analysis of its Prevalence and a Critical Appraisal of its Measurement

doi:10.21203/rs.3.rs-7650603/v1

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Systematic Review

The Impostor Phenomenon Construct in Medical Education: A Meta-Analysis of its Prevalence and a Critical Appraisal of its Measurement

https://doi.org/10.21203/rs.3.rs-7650603/v1

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Impostor phenomenon (IP) is widely cited as a significant challenge in medical education, yet its conceptual and methodological foundations are unstablem, hindering a clear understanding of its true scope and impact. Thus, this systematic review and meta-analysis aimed to first establish a pooled prevalence of IP among medical students, and second, to critically appraise the measurement tools and definitions used in the literature. We systematically searched PubMed, Scopus, Web of Science, and CINAHL through July 2025 for all studies quantitatively assessing IP prevalence in medical students. Using a random-effects model, we analyzed data from 34 studies, including 9,550 participants. The overall pooled prevalence of IP was 49% (95% CI [0.43–0.54]), but this figure is complicated by extreme heterogeneity across studies (I² = 95.6%, P < 0.001) despite multiple sensitivity analyses. Subgroup analyses revealed significant prevalence differences by sex (females 51% vs. males 40%; P = 0.021), geographic region (P < 0.001), and the measurement tool used (P < 0.001). The qualitative synthesis suggested associations between IP and negative mental health outcomes, including anxiety, depression, and burnout. Nevertheless, the variance driven by different measurement tools suggests that researchers may not be consistently measuring the same construct. The reliance on unvalidated cutoffs further weakens the validity of prevalence estimates. We conclude that while IP is clearly a prevalent concern, the construct's weak theoretical grounding and inconsistent measurement impede meaningful progress. Advancing this area of medical education research requires a foundational shift toward conceptual clarity and methodological rigor.

Imposter phenomenon

Imposter syndrome

Medical students

Prevalence

Systematic review

Meta-analysis

First described by Clance and Imes in 1978 (Clance & Imes, 1978), imposter phenomenon (IP), also referred to as imposter syndrome, is characterized by an inability to internalize success, leading to deep-seated self-doubt in one's intellectual and professional competence. Individuals experiencing IP struggle to realistically assess their competence and skills, often attributing their success to external factors such as luck (Clance & Imes, 1978; Gullifor et al., 2024). Initially thought to affect only certain populations (Clance & Imes, 1978), research now suggests that up to 70% of individuals experience IP at some point in their careers (Gravois, 2007; Sakulku, 2011). In highly stressful environments such as higher education, where intellect is highly regarded and self-worth is closely tied to academic performance, these feelings intellectual fraudulence can easily arise and persist (De Vries, 2005). This is especially true among medical students, who face significant academic stress, and are particularly vulnerable to both self-imposed and external expectations (Alsaleem et al., 2021; El-Setouhy et al., 2024).

In high-stakes fields such as healthcare, where even minor mistakes can have serious consequences, it is no surprise that medical professionals often develop maladaptive perfectionism and struggle with self-doubt (Chodoff et al., 2023; Martin et al., 2022). These traits often begin to develop early on in medical education, where students face rigorous academic demands and a highly competitive environment. As they advance through their training, these stressors intensify, exacerbating feelings of impostorism and self-perceived fraudulence (Houseknecht et al., 2019). Furthermore, the hierarchical structure of medical education and the broader culture of medicine may reinforce these feelings, as admitting uncertainty or seeking help is often perceived as a sign of weakness (Gottlieb et al., 2020). This competitive environment fosters a cycle of self-doubt (Kim et al., 2024), maladaptive perfectionism (Hu et al., 2019), and burnout (Sivananthajothy et al., 2024), ultimately compromising both professional development and well-being (Houseknecht et al., 2019).

A 2019 scoping review estimated the prevalence of IP among trainees and practicing physicians to range from 22% to 60% (Gottlieb et al., 2020). However, research on IP among medical students has increased significantly in recent years. Since then, studies have linked IP in medical students to various negative professional and personal outcomes. Students experiencing IP report heightened stress, anxiety, depression, and burnout compared to their peers (Hu et al., 2019; Vilchez-Cornejo et al., 2021). Additionally, they consistently exhibit lower self-esteem, increased self-doubt (Kim et al., 2024), and a weakened sense of professional identity (Houseknecht et al., 2019). If left unaddressed, these challenges may persist into medical training and practice, ultimately impacting professional development and patient care (LaDonna et al., 2018; Stelling et al., 2023).

The wide variation in reported IP prevalence among medical students suggests fundamental issues in how the construct is defined and measured. Therefore, this study aims to first synthesize the existing data to quantify the extent of IP and its heterogeneity, and second, to use this synthesis as a basis for a critical appraisal of the field's methodological rigor and conceptual clarity.

We followed the recommendations of the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines while reporting this manuscript (Page et al., 2021). This study was prospectively registered on PROSPERO with the registration number CRD420250653498.

Eligibility criteria and literature search strategy

We included all studies that quantitatively assessed IP among medical students using validated measurement tools, such as the Clance Impostor Phenomenon Scale (CIPS) (Clance, 1986) and Young Impostor Score (YIS) (Villwock et al., 2016). Students were classified as experiencing IP if they met the respective scale’s cutoff. For example, reporting frequent to intense impostor feelings on the CIPS, scoring ≥ 5 "Yes" responses or a total score of > 40 on the YIS, or scoring ≥ 25 on the Leary Impostor Scale (LIS) (Brennan-Wydra et al., 2021).

Studies were excluded if they assessed IP through self-identification, non-validated tools, or qualitative methods. We also excluded studies focused on non-medical student populations (e.g., nursing, dental students, or interns), as well as those that reused the same sample for different analyses (e.g., factor analysis). Studies that did not report the discrete prevalence of IP among medical students were included in the review but excluded from the quantitative synthesis. Review articles, commentaries, and editorials were also excluded.

We initially searched PubMed, Scopus, Web of Science, and CINAHL on February 9, 2025. Due to the time required for screening and data extraction, we conducted an updated search on July 9, 2025, to capture any articles published in the interim. Our search strategy included synonyms for IP (e.g., impostor syndrome, impostorism) and medical students (e.g., medical trainees, health profession students). The query was adapted for each database, and the full search strategy is provided in Table S1 (Online Resource1).

Selection process and data extraction

Eligibility screening was conducted in two stages using Rayyan software (Ouzzani et al., 2016). First, titles and abstracts of all retrieved papers were screened. Next, full texts of eligible studies were reviewed to determine their suitability for meta-analysis. Three authors independently conducted the selection process, with any disagreements resolved through consultation with a fourth author.

Data extraction was performed independently by three authors using an online extraction sheet on Google Sheets. Extracted data included study design characteristics, population details, assessment tools used, cutoff score employed, reported prevalence of IP (if available), and any secondary outcomes examined in relation to IP.

Quality assessment

Three authors independently assessed the quality of the included studies. Although the dataset included studies with varying designs (cross-sectional, longitudinal, and pre-post interventional), only baseline (cross-sectional) data were extracted for the meta-analysis of prevalence. Accordingly, all studies were evaluated using the Newcastle-Ottawa Scale (NOS) adapted for cross-sectional studies (Herzog et al., 2013). The scale evaluates studies across three domains: Selection, Comparability, and Outcome, and classifies studies as unsatisfactory (0–4), satisfactory (5–6), good (7–8), or very good (9–10).

Data synthesis and Publication bias

A meta-analysis model was conducted to determine the pooled prevalence of IP among medical students. We estimated the pooled prevalence using the random effects model with a 95% confidence interval (CI), allowing for modeling of the underlying variance in the prevalence of each study while pooling across studies. For each study, the observed prevalence of IP was treated as a dichotomous outcome (event/total).

We conducted analysis determining the general prevalence of IP, as well as the of IP based on sex, academic year, and region, tool used, and study quality. A random-effect model was used in each analysis due to the underlying heterogeneity between the studies. Heterogeneity was assessed by visual inspection of the I² and Tau² tests found in the forest plots. A P-value less than 0.1 indicates significant heterogeneity.

To assess the robustness of our findings and explore sources of heterogeneity, we conducted a comprehensive sensitivity analysis. We identified potential outliers by examining studentized residuals and used Baujat plots to visualize each study's contribution to both heterogeneity and the pooled effect. Formal influence diagnostics, including Cook's distance, were used to pinpoint studies that disproportionately affected the summary estimate. To ensure our main conclusion wasn't driven by any single study, we also performed a leave-one-out meta-analysis, iteratively removing one study at a time and recalculating the results.

According to the pre-specified inclusion and exclusion criteria in this study, more than ten studies entered the meta-analysis model. As a result, we performed Egger’s test that examines the potential asymmetry of funnel plots to assess publication bias (Egger et al., 1997). A p-value less than 0.05 indicates the potential presence of publication bias. All the analyses were conducted using R software version 4.3.3 (Team, 2010), and the meta (Schwarzer et al., 2015) and dmetar packages (Harrer et al., 2019).

Due to substantial outcome reporting heterogeneity, a meta-analysis of secondary outcomes was not feasible. Therefore, a narrative synthesis of correlates was conducted instead.

Search results

Our search retrieved 992 unique studies, of which 451 were duplicates. After removing duplicates, 541 studies remained for title and abstract screening. Following this screening, 492 studies were excluded, leaving 49 studies for full-text eligibility assessment. Of the 49 studies, 44 met the inclusion criteria and were included in the review. However, only 34 studies reported the discrete prevalence of IP among medical students and thus met the criteria for inclusion in the quantitative analysis. Figure 1 presents the PRISMA flow diagram detailing the study identification and selection process.

Study characteristics

The characteristics of the included studies are presented in Table 1. A total of 44 studies, including 12,345 medical students, met the criteria for inclusion in the systematic review. However, the prevalence of IP was available for only 9,550 students, and only these were included in the quantitative synthesis. The pooled mean age of the participants was approximately 22.1 years, and the pooled percentage of female participants was 55.5% (Table 1).

Table 1
Summary of studies included in the systematic review and meta-analysis of imposter phenomenon among medical students
Study ID	Country	Study Design & Population	Medical students' characteristics	Tool	Quality score¹	Prevalence of IP, n (%)	Key findings
Addae-Konadu 2021 (Addae-Konadu et al., 2022)	USA	Cross-sectional – Medical students, residents, fellows, and attendings	64 students, NR female, NR mean age	CIPS	6	47 (73.4)	No significant difference in impostor phenomenon (IP) by gender, race, or region. Higher IP among those screening positive for anxiety.
Al Lawati 2023 (Al Lawati et al., 2023)	Oman	Cross-sectional – Medical students	276 students, 65.9% female, NR mean age	CIPS	7	144 (52.2)	No significant difference in IP by gender.
Alok 2024 (Alok et al., 2024)	India	Cross-sectional – Medical students	377 students, NR female, NR mean age	CIPS	4	NA	IP positively correlated with stress, anxiety, and depression.
Alsaleem 2021 (Alsaleem et al., 2021)	Saudi Arabia	Cross-sectional – Medical students	573 students, 46.8% female, 21.27 years (mean age)	YIS	7	241 (42.1)	Higher IP in females; no association with GPA, income, or family background.
Alzufari 2024 (Alzufari et al., 2024)	UAE	Cross-sectional – Medical and dentistry students	197 students, 59.6% female, NR mean age	CIPS	8	91 (46.2)	IP correlated with advisor’s attitude and comparison with peers’ performance and grades.
Brennan-Wydra 2021 (Brennan-Wydra et al., 2021)	USA	Cross-sectional – Medical students	226 students, 53.1% female, NA mean age	LIS	7	41 (18.1)	Higher IP in females; positively correlated with maladaptive perfectionism and suicidal ideation.
Buathong 2024 (Buathong et al., 2023)	Thailand	Cross-sectional – Medical students	272 students, 59.6% female, 21.55 ± 1.80 years	CIPS	6	125 (46)	IP significantly associated with permissive parenting style, stressful life events, financial difficulties, and poor interpersonal relationships. Higher IP observed in individuals with anxiety, depression, low self-esteem, and those using emotive/palliative coping strategies.
Camara 2022 (Camara et al., 2022)	Brazil	Cross-sectional – Medical students	425 students, 36.2% female, 23.03 ± 5.0 years	CIPS	5	203 (47.76)	No significant differences in IP by age, gender, semester, or religion. IP negatively correlated with resilience.
Choron 2022 (Choron et al., 2023)	USA	Cohort – Medical students	30 students, 0.3% female, 27 years	CIPS	6	20 (66.67)	No significant difference in IP by race or breaks in training. IP positively correlated with longer periods working outside medicine.
Clark 2024 (Clark et al., 2024)	USA	Cross-sectional – Medical students	89 students, 64.0% female, NA mean age	CIPS	4	51 (57.3)	Higher IP among females, fourth-year students, first-generation college students, and students from rural backgrounds.
De 2024 (De et al., 2024)	India	Cross-sectional – Medical students	130 students, 42.3% female, NA mean age	CIPS	7	63 (48.5)	Higher IP in females. IP positively correlated with sleeping more than 56 hours per week, good academic performance, middle-class background, family psychiatric history, chronic medication use, and being in the second semester.
Diaconescu 2024 (Diaconescu et al., 2024)	Romania	Cross-sectional – Medical students	331 students, 69.2% female, 21.18 years	CIPS	8	205 (61.93)	IP negatively associated with self-esteem. Marginally significant impact of IP on academic performance.
El-Setouhy 2024 (El-Setouhy et al., 2024)	Saudi Arabia	Cross-sectional – Medical students	523 students, 41.3% female, 22.1 ± 1.9 years	YIS	7	127 (24.3)	IP positively correlated with being in the second academic year, the reason for choosing medicine, hours of sleep, and GPA. Negatively correlated with self-esteem. No association with gender, monthly family income, parental education level, or BMI.
Elnaggar 2023 (Elnaggar et al., 2023)	Saudi Arabia	Cross-sectional – Medical students	165 students, 52.1% female, NA mean age	CIPS	6	70 (42.42)	No difference in IP by gender or academic phase. Positively correlated with a GPA < 3.
Franchi 2022 (Franchi & Russell-Sewell, 2023)	UK	Cross-sectional – Medical students	191 students, 71.2% female, 21.10 ± 2.64 years	CIPS	6	125(65.4)	Higher IP in females, with severity positively correlated with self-criticism, fear of failure, and perfectionism.
Gupta 2025 (Gupta et al., 2025)	India	Cross-sectional – Medical students	104 students, 51.9% female, NR mean age	HIPS, ≥ 42	20 (19.2)	Good	IP correlated positively with perceived stress scores, and negatively with coping ability.
Henning 1998 (Henning et al., 1998)	USA	Cross-sectional – Medical, dental, nursing, and pharmacy students	221 students, 53.0% female, 26.2 ± 5 years	CIPS	6	NA	Higher IP in females and early academic years. Lower distress in minority students, with no association to IP.
Herța 2024 (Herța et al., 2024)	Romania	Cross-sectional – Medical students	162 students, 59.0% female, NR mean age	CIPS	3	NA	Positive correlation of burnout and emotional exhaustion (a component of burnout) with overall impostor perception among international medical students.
Holliday 2019 (Holliday et al., 2020)	USA	Cross-sectional – Medical and dental students	343 students, NR female, 25 ± 3 years	CIPS	5	NA	Higher IP in females. No significant association between IP and being originally Hispanic or Latino.
Houseknecht 2019 (Houseknecht et al., 2019)	USA	Longitudinal – Medical students	110 students, NR female, NR mean age	CIPS	7	NA	From pre year 1 to post third-year clerkships, wellness and professional identity decreased, IP increased while calling did not change.
Hu 2019 (Hu et al., 2019)	USA	Cross-sectional – Medical students	169 students, 58.9% female, NR mean age	CIPS	5	54 (31.9)	Positive correlation of high/intense IP with increased feelings of shame, embarrassment, and inadequacy.
Khalil 2024 (Khalil AI, 2024)	Saudi Arabia	Cross-sectional – Medical and nursing students	98 students, NR female, 21.4 ± 2.24 years	CIPS	7	52 (53.1)	IP was negatively associated with resilience.
Kim 2024 (Kim et al., 2024)	USA	Cross-sectional – Medical students	29 students, 58.3% female, NR mean age	CIPS	5	22 (75.9)	More frequent IP in females, students without prior military service, and those with three or more gap years.
Klen 2023 (Kolenc Klen et al., 2025)	Slovenia	Cross-sectional – Medical students	207 students, 64.3% female, 23.2 ± 2.6 years	CIPS	6	120 (58)	Higher IP in females, with no significant associations with age, year of study, or prior clinical work experience.
Kristofferson 2024 (Kristoffersson et al., 2024)	Sweden	Cross-sectional – Medical students	457 students, 62.6% female, NR mean age	CIPS	6	275 (60.2)	Higher IP and lower resilience scores in females; IP negatively associated with resilience.
Levant 2020 (Levant et al., 2020)	USA	Cross-sectional – Medical students	112 students, NR female, 25.8 ± 3 years	CIPS	6	NA	No association between responses to specific items and self-reported underrepresented minority status.
Mashhadi 2022 (Mashhadi et al., 2022)	Pakistan	Cross-sectional – Medical and dental students	362 students, NR female, NR mean age	CIPS	5	240 (66.3)	IP significantly associated with gender, age, academic performance, and year of study. No significant associations with ethnicity, religion, hometown, college type, city, birth order, or total family income.
Naser 2022 (Naser et al., 2022)	Bahrain	Cross-sectional – Medical students	290 students, 58.3% female, NR mean age	CIPS	5	131(45.2)	IP negatively associated with self-esteem, with small associations with marital status. No significant associations with gender, age, degree status, year of study, pre-clinical vs. clinical stage, domestic vs. international status, or geographical region.
Neufeld 2022 (Neufeld et al., 2023)	Canada	Cross-sectional – Medical students	277 students, 64.3% female, NR mean age	CIPS	7	204 (73.3)	IP significantly associated with gender, impersonal general causality orientation, and controlled motivation for pursuing medical school. No association with ethnic minority status, autonomy, competence, relatedness satisfaction in the medical program, autonomy general causality orientation, or autonomous motivation.
Ogunyemi 2022 (Ogunyemi et al., 2022)	USA	Pre-post – Medical students, resident physicians, administrators and directors	18 students, 77.5% female, NR mean age	YIS	7	NA	Participants with impostor syndrome competence subtypes reported increased perceptions of IP as a source of stress, a barrier to reaching full potential, and a factor in negative relationships and teamwork.
Priya 2024 (Priya et al., 2024)	India	Cross-sectional – Medical students	249 students, 57.0% female, NR mean age	CIPS	6	103 (41.36)	No association of IP with gender or self-esteem.
Qureshi 2017 (Qureshi et al., 2017)	India	Cross-sectional – Medical students	143 students, 58.7% female, 24.08 ± 1.05 years	YIS	5	68 (47.5)	No association of IP with gender.
Rice 2023 (Rice et al., 2023)	USA	Cross-sectional – Medical students	278 students, 60.0% female, NA mean age	CIPS	6	162 (58.3)	Higher IP in females and in students at Predominantly White Institutions (PWI) compared to those at Historically Black Colleges/Universities (HBCU). Higher IP in Underrepresented in Medicine (UiM) students at PWIs than UiM students at HBCUs, as well as in non-UiM students at PWIs compared to non-UiM students at HBCUs. No association of IP with UiM status.
Rosenthal 2021 (Rosenthal et al., 2021)	USA	Longitudinal – Medical students	257 students, 50.2% female, NA mean age	CIPS	7	82(32)	Higher IP and greater neuroticism/anxiety in females. IP increased from matriculation to the end of the first year. Significant associations of IP with specific personality traits across genders. Positive correlation of IP with neuroticism/anxiety and loneliness. Negative correlation of IP with self-compassion, sociability, self-esteem, interpersonal relationships, and health status.
Sawant 2023 (Sawant et al., 2023)	India	Cross-sectional – Medical students and interns	371 students, NA female, NA mean age	CIPS	5	NA	IP associated with medical year. No association of gender with IP, extraversion, openness, or self-esteem. Negative correlations of IP with self-esteem, extraversion, agreeableness, and conscientiousness. Positive correlation of IP with neuroticism. No association of IP with openness.
Shill-Russell 2022 (Shill-Russell et al., 2022)	USA	Cross-sectional – Medical students	600 students, 50.2% female, NA mean age	YIS	5	NA	Higher IP in females. No association of IP with intercept, science GPA, MCAT score, or the interaction between science GPA and MCAT score.
Shinawatra 2023 (Shinawatra et al., 2023)	Thailand	Cross-sectional – Medical students	228 students, 59.6% female, NA mean age	CIPS	6	108 (47.4)	No association of IP with gender, medical year, ward rotation, training location, GPA, or family background. Positive correlations of IP with anxiety, stress, and depression.
Shreffler 2020 (Shreffler et al., 2021)	USA	Cross-sectional – Medical students	233 students, 45.6% female, NA mean age	CIPS	6	98(42.1)	No association of IP with medical year or USMLE scores.
Sivananthajothy 2024 (Sivananthajothy et al., 2024)	Canada	Cross-sectional – Medical students	480 students, 72.5% female, NR mean age	CIPS	6	NA	Positive correlation of IP with depression, burnout, and interactions with medical student peers, faculty/preceptor/staff representation, and sense of belonging. Negative correlations of IP with representation, peer and faculty interactions, and sense of belonging. Faculty/preceptor/staff representation negatively correlated with depression and burnout. Sense of belonging negatively correlated with depression and burnout. Depression and burnout negatively correlated with representation.
Tran 2024 (Tran et al., 2022)	USA	Pre-post – Medical students	113 students, NA female, NR mean age	CIPS	5	NA	After the module, more participants recognized the impact of IP on themselves and others and reported greater confidence in managing its effects. 94% of first-year participants agreed on the module’s importance in their medical education.
Vilchez-Cornejo 2023 (Vilchez-Cornejo et al., 2021)	Peru	Cross-sectional – Medical students	2231 students, 54.3% female, 21 years	CIPS	6	682 (30.6)	IP negatively associated with self-esteem. Higher IP in females, fourth-year students, and those experiencing depression, anxiety, or stress.
Villwok 2016 (Villwock et al., 2016)	USA	Cross-sectional – Medical students	138 students, 56.2% female, NA mean age	YIS	7	54 (39.1)	Higher IP in females. Negative correlation of IP with being Asian or white. Significant associations of IP with exhaustion, cynicism, emotional exhaustion, depersonalization, and being in the fourth year.
Wang 2023 (Wang et al., 2024)	China	Cross-sectional – Medical students and residents	148 students, 60.1% female, NA mean age	CIPS	6	93 (62.8%)	No difference in IP between students and residents based on time allocated to research. No association of IP with gender, clinical work and learning hours, research hours, sleep hours, or time allocated to entertainment or self-care. Positive correlations of IP with enrollment in the eight-year program compared to the 4 + 4 program and feeling challenged by clinical learning. Associations of IP with anxiety, depression, insomnia, and burnout.
Wrench 2024 (Wrench et al., 2024)	USA	Pre-post – Medical students	48 students, 52.0% female, NA mean age	YIS	7	19 (40)	Higher IP in females. Positive correlation of IP with being ≤ 24 years old. No association of IP with ethnicity or being 25–29 years old.
Abbreviations: IP – Impostor Phenomenon; CIPS – Clance Impostor Phenomenon Scale; HIPS – Harvey Impostor Phenomenon Scale; LIS – Leary Impostor Scale; YIS – Young Impostor Score; NR – Not Reported; NA – Not Available; GPA – Grade Point Average; USA – United States of America; UAE – United Arab Emirates; UK – United Kingdom. ¹Quality scores were assessed using the Newcastle-Ottawa Scale (NOS) Adapted for Cross-sectional Studies.

Of the 44 included studies, the majority were cross-sectional, while four were pre-post studies (Choron et al., 2023; Ogunyemi et al., 2022; Tran et al., 2022; Wrench et al., 2024), and two were longitudinal studies (Houseknecht et al., 2019; Rosenthal et al., 2021). The studies were published between 1998 and 2025, with more than half being published in the last three years. The studies were conducted across 18 countries, with the highest number originating from the United States (18 studies), followed by India (6 studies) and Saudi Arabia (4 studies). The majority of studies utilized the CIPS, while seven studies used the YIS (Alsaleem et al., 2021; El-Setouhy et al., 2024; Ogunyemi et al., 2022; Qureshi et al., 2017; Shill-Russell et al., 2022; Villwock et al., 2016; Wrench et al., 2024), and only one study used each of the LIS (Brennan-Wydra et al., 2021) and the Harvey Imposter Phenomenon Scale (HIPS) (Gupta et al., 2025).

Most studies were of good or satisfactory quality, with only three studies rated as unsatisfactory quality (Alok et al., 2024; Herța et al., 2024; Tran et al., 2022) (See Table S2 (Online Resource1) for an overview of the quality ratings of each study). By running Linear regression test of funnel plot asymmetry (Egger’s test), significant publication bias is detected (Egger’s test P = 0.02). The funnel plot assessing publication bias is presented in Figure S1 (Online Resource1).

Meta-analysis of Prevalence of Imposter Phenomenon

Overall Prevalence of Impostor Phenomenon Among Medical Students

A total of 34 studies were included in single proportion meta-analysis with a total of 9550 students. The pooled overall prevalence of impostor syndrome in medical students using a random effects model was 49% (PR = 0.49, 95% CI [0.43 to 0.54]). Pooled studies were not homogenous (I2 = 95.6%, P < 0.001). The forest plot of overall prevalence of IP Among medical students is presented in Fig. 2.

Prevalence of Impostor Phenomenon by Sex

Data on sex subgroups were reported from 20 studies for males (N = 3097) and 19 for females (N = 3491). The pooled prevalence of IP was 40% (PR = 0.40, 95% CI [0.35 to 0.46]) in males and 51% (PR = 0.51, 95% CI [0.44 to 0.58]) in females. Heterogeneity was high in both subgroups (males, I2 = 87.5%, P < 0.001; females, I2 = 93.3%, P < 0.001). Test for subgroup differences revealed a statistically significant difference between prevalences of IP among males and females (χ² = 5.31, P = 0.021). Detailed results are presented in Fig. 3 and the forest plot of prevalence of IP by sex is presented in Figure S2 (Online Resource1).

Prevalence of Impostor Phenomenon by Academic Year

Ten studies reported data for 1st-year students (N = 1314) with a pooled IP prevalence of 45% (PR = 0.45, 95% CI [0.36–0.55]); eight studies for 2nd-year students (N = 996) with 42% (PR = 0.42, 95% CI [0.35–0.49]); nine studies for 3rd-year students (N = 954) with 37% (PR = 0.37, 95% CI [0.30–0.45]); ten studies for 4th-year students (N = 1095) with 42% (PR = 0.42, 95% CI [0.37–0.47]); seven studies for 5th-year students (N = 645) with 37% (PR = 0.37, 95% CI [0.26–0.49]); and three studies for 6th-year students (N = 466) with 31% (PR = 0.31, 95% CI [0.19–0.47]). Heterogeneity was high across all subgroups. The test for subgroup differences showed no significant variation in IP prevalence between academic years (χ² = 3.95, P = 0.557). Detailed results are presented in Fig. 3 and the forest plot of prevalence of IP by academic year is shown in Figure S3 (Online Resource1).

Prevalence of Impostor Phenomenon by Region

The pooled prevalence of IP varied by region. In North America, 13 studies (N = 1950) reported a prevalence of 50% (PR = 0.50, 95% CI [0.40–0.61]; I² = 94.9%, P < 0.001). In South America, two studies (N = 2656) reported 39% (PR = 0.39, 95% CI [0.27–0.51]; I² = 97.8%, P < 0.001). In Asia, eight studies (N = 1636) reported 47% (PR = 0.47, 95% CI [0.38–0.57]; I² = 92.2%, P < 0.001). In the MENA region, seven studies (N = 2122) reported 43% (PR = 0.43, 95% CI [0.36–0.50]; I² = 92.7%, P < 0.001). In Europe, four studies (N = 1186) reported 61% (PR = 0.61, 95% CI [0.58–0.64]; I² = 0%, P = 0.453). A test for subgroup differences indicated a statistically significant variation in prevalence between continents (χ² = 36.15, P < 0.001). Detailed results are presented in Fig. 3 and the forest plot of prevalence of IP by continent is shown in Figure S4 (Online Resource1).

Prevalence of Impostor Phenomenon by Tool

The pooled prevalence of IP varied significantly depending on the assessment tool used. For studies using the CIPS, 27 studies (N = 7795) yielded a pooled prevalence of 53% (PR = 0.53, 95% CI [0.48 to 0.58]) with very high heterogeneity (I2 = 95.4%, P < 0.001). For YIS, five studies (N = 1425) showed a pooled prevalence of 38% (PR = 0.38, 95% CI [0.30 to 0.46]), also with high heterogeneity (I2 = 91.7%, P < 0.001). Single studies using LIS (N = 226) and HIPS (N = 104) reported prevalences of 18% (PR = 0.18, 95% CI [0.14 to 0.24]) and 19% (PR = 0.19, 95% CI [0.13 to 0.28]), respectively. A test for subgroup differences indicated a statistically significant difference in the prevalence of IP among the different tools (χ2 = 84.79, P < 0.001). Detailed results are presented in Fig. 3 and the forest plot of prevalence of IP by tool is presented in Figure S5 (Online Resource1).

Prevalence of Impostor Phenomenon by Study Quality

The pooled prevalence of IP varied by study quality. Among studies rated as good quality (n = 14; N = 5317), prevalence was 42% (PR = 0.42, 95% CI [0.33–0.51]; I² = 96.7%, P < 0.001). Among satisfactory-quality studies (n = 20; N = 4233), prevalence was 53% (PR = 0.53, 95% CI [0.48–0.58]; I² = 90.0%, P < 0.001). The difference between quality groups was statistically significant (χ² = 4.54, P = 0.033). Detailed results are presented in Fig. 3 and the forest plot of prevalence of IP by study quality is shown in Figure S6 (Online Resource1).

Sensitivity Analysis

We performed several sensitivity studies to evaluate the strength of our conclusions. Several studies were shown to be substantially contributing to both heterogeneity and the overall effect by Baujat and influence diagnostics, which are shown in Figure S7 and S8 respectively. The most significant of these studies was Vilchez-Cornejo (2023). A sensitivity analysis removing 14 identified outliers produced a pooled proportion of 48% (PR = 0.48, 95% CI [0.45 to 0.51]) and reduced heterogeneity to I2 = 65.4%. The forest plot in Figure S9 visualizes this updated analysis, verifying that there was no significant change to our main finding. Finally, our leave-one-out analysis forest plot, shown in Figure S10, demonstrates that the pooled estimate was not driven by any single study (Online Resource1). While the effect size remained stable throughout this iterative process, the plot also shows that substantial heterogeneity persisted in every iteration, indicating that rather than being the result of one or two significant studies, the observed variability is a general feature of the dataset.

Narrative Synthesis of Correlates of Imposter Phenomenon

Impostor Phenomenon and Sociodemographic Factors

The association between IP and gender appears inconsistent. While several studies reported higher IP scores among female medical students (Alsaleem et al., 2021; Brennan-Wydra et al., 2021; Clark et al., 2024; De et al., 2024; Franchi & Russell-Sewell, 2023; Henning et al., 1998; Holliday et al., 2020; Kim et al., 2024, 2024; Kolenc Klen et al., 2025; Kristoffersson et al., 2024; Mashhadi et al., 2022; Rice et al., 2023; Rosenthal et al., 2021; Shill-Russell et al., 2022; Vilchez-Cornejo et al., 2021; Villwock et al., 2016; Wrench et al., 2024), other studies found no significant association (Addae-Konadu et al., 2022; Al Lawati et al., 2023; Camara et al., 2022; Elnaggar et al., 2023; El-Setouhy et al., 2024; Priya et al., 2024; Qureshi et al., 2017; Sawant et al., 2023; Shinawatra et al., 2023; Wang et al., 2024). Findings on the association between IP and academic year and age were also inconsistent. Some studies reported higher IP scores in earlier years of medical education (Henning et al., 1998), while others found increased IP in later years, particularly among fourth-year students (Clark et al., 2024; Vilchez-Cornejo et al., 2021; Villwock et al., 2016). Other studies found no significant association between IP and academic year (Camara et al., 2022; Sawant et al., 2023; Shreffler et al., 2021; Wang et al., 2024). In terms of age, one study reported higher IP scores among younger students (≤ 24 years old) (Wrench et al., 2024), though other studies reported no significant age-related differences (Camara et al., 2022; Kolenc Klen et al., 2025; Mashhadi et al., 2022). In one study, IP was higher among first-generation college students and those from rural backgrounds (Clark et al., 2024).

Several studies reported no association between IP and income level or parental education (Alsaleem et al., 2021; El-Setouhy et al., 2024; Mashhadi et al., 2022), although Buathong et al. reported a significant association between IP and permissive parenting style and financial difficulties (Buathong et al., 2023). Similarly, while multiple studies found no significant association between race and IP (Addae-Konadu et al., 2022; Choron et al., 2023; Levant et al., 2020; Neufeld et al., 2023; Shill-Russell et al., 2022; Wrench et al., 2024), Rice et al. reported higher IP in students attending Predominantly White Institutions (PWIs) compared to Historically Black Colleges and Universities (HBCUs), with underrepresented in medicine (UiM) students at PWIs experiencing greater IP than those at HBCUs (Rice et al., 2023).

Psychological Correlates of Impostor Phenomenon

Among the studies included in this review, IP was frequently associated with adverse mental health outcomes. Multiple studies found a positive association between IP and stress, anxiety, and depression (Alok et al., 2024; Brennan-Wydra et al., 2021; Buathong et al., 2023; Rosenthal et al., 2021; Shinawatra et al., 2023; Vilchez-Cornejo et al., 2021). Moreover, IP was associated with burnout and emotional exhaustion (Herța et al., 2024; Sivananthajothy et al., 2024; Villwock et al., 2016). Conversely, resilience (Camara et al., 2022; Khalil AI, 2024; Kristoffersson et al., 2024), self-esteem (Alsaleem et al., 2021; Buathong et al., 2023; Diaconescu et al., 2024; El-Setouhy et al., 2024; Franchi & Russell-Sewell, 2023; Hu et al., 2019; Naser et al., 2022; Priya et al., 2024; Rosenthal et al., 2021; Sawant et al., 2023; Vilchez-Cornejo et al., 2021), self-compassion (Rosenthal et al., 2021), and sense of belonging (Sivananthajothy et al., 2024) were negatively correlated with IP.

In terms of personality traits, IP was positively associated with maladaptive perfectionism and fear of failure (Brennan-Wydra et al., 2021; Franchi & Russell-Sewell, 2023). Neuroticism and anxiety were also positively correlated with IP, whereas extraversion, agreeableness, and conscientiousness showed negative correlations (Rosenthal et al., 2021; Sawant et al., 2023).

Academic Correlates of Impostor Phenomenon

Studies produced mixed findings regarding the association between IP and academic performance. Some reported a positive correlation between IP and good academic performance (De et al., 2024; El-Setouhy et al., 2024), whereas others found a negative association (Diaconescu et al., 2024; Elnaggar et al., 2023; Levant et al., 2020). No significant association was found between IP and GPA in multiple studies (Alsaleem et al., 2021; Shill-Russell et al., 2022).

In one study, IP was associated with advisor attitudes and comparison with peers’ grades (Alzufari et al., 2024), while another study found that lower faculty representation was linked to higher impostor feelings (Sivananthajothy et al., 2024). Moreover, two studies reported that professional identity declined as IP increased during medical training (Houseknecht et al., 2019; Hu et al., 2019). Additionally, Franchi et al. found that IP was strongly influenced by examination rankings, high-pressure academic culture, and fear of failure (Franchi & Russell-Sewell, 2023).

This systematic review and meta-analysis provides the first quantitative synthesis of IP prevalence in medical students, revealing two primary findings. First, IP is a common experience, affecting an estimated 49% of students globally. Second, and more critically, this prevalence estimate is undermined by extreme statistical heterogeneity that could not be resolved by sensitivity analyses. Our subgroup analyses show that prevalence estimates are highly dependent on the choice of measurement tool, in addition to variations by sex and region. This suggests that the current body of research lacks the conceptual and methodological consistency required to generate robust, generalizable knowledge.

Our meta-analysis suggests that nearly one in every two medical students experiences IP (49%), providing a more precise estimate than the broader ranges narratively reported in previous reviews. For instance, Judie et al. (2022) identified prevalence estimates among medical students ranging from 29.5% to 51% (Judie et al., 2022), while Gottlieb et al. (2019) reported a wider range of 22% to 60% among physicians and physicians in training (Gottlieb et al., 2020). Salari et al. reported a higher prevalence of 62% among health service providers (Salari et al., 2025), though their review included heterogeneous populations such as faculty members, pre-service educators, and engineers, and did not conduct any subgroup analysis to address this variability. Our refined estimate is further supported by our inclusion of more than twice the number of studies available at the time of these reviews, reflecting the growing research on IP in medical education. However, prevalence was not uniform across all groups, with notable differences observed based on sex, academic year, and geographic region.

Sex is the most commonly studied demographic factor in the IP literature, which is not surprising given that the phenomenon was first identified among high-achieving women (Clance & Imes, 1978). Since then, research has expanded, with recent systematic reviews concluding that IP is not limited to one sex (Bravata et al., 2020; Gullifor et al., 2024). Concurrently, IP was indeed prevalent across different genders in our review. However, this prevalence was not equal. While some studies reported higher IP scores among female medical students (Alsaleem et al., 2021; Brennan-Wydra et al., 2021; Clark et al., 2024; De et al., 2024; Franchi & Russell-Sewell, 2023; Henning et al., 1998; Holliday et al., 2020; Kim et al., 2024, 2024; Kolenc Klen et al., 2025; Kristoffersson et al., 2024; Mashhadi et al., 2022; Rice et al., 2023; Rosenthal et al., 2021; Shill-Russell et al., 2022; Vilchez-Cornejo et al., 2021; Villwock et al., 2016; Wrench et al., 2024), and others found no significant association (Addae-Konadu et al., 2022; Al Lawati et al., 2023; Camara et al., 2022; Elnaggar et al., 2023; El-Setouhy et al., 2024; Priya et al., 2024; Qureshi et al., 2017; Sawant et al., 2023; Shinawatra et al., 2023; Wang et al., 2024), our meta-analysis provides compelling evidence that, overall, IP is significantly more prevalent among females, at least within the context of medical students.

The higher prevalence of IP among females can be potentially understood through Gullifor et al.'s conceptual framework (Gullifor et al., 2024), which suggests that the phenomenon may manifest both as a stable personality trait and a transient psychological state, influenced by individual predispositions and external academic pressures. This increased prevalence in females may reflect a greater susceptibility to trait-like tendencies such as perfectionism (Madigan, 2019), self-doubt (Vajapey et al., 2020), and societal expectations (Kågesten et al., 2016), all of which have been consistently reported at higher levels in women and were found to be correlated with IP in several studies within this review (Brennan-Wydra et al., 2021; Franchi & Russell-Sewell, 2023). Furthermore, women may experience lower levels of self-esteem, which was also negatively associated with IP in multiple studies (Alsaleem et al., 2021; Buathong et al., 2023; Diaconescu et al., 2024; El-Setouhy et al., 2024; Franchi & Russell-Sewell, 2023; Hu et al., 2019; Naser et al., 2022; Priya et al., 2024; Rosenthal et al., 2021; Sawant et al., 2023; Vilchez-Cornejo et al., 2021). Beyond individual factors, the medical education environment itself may reinforce impostor feelings, as women navigating male-dominated fields often face greater pressure to prove their competence, exacerbating self-doubt and impostor experiences (Franchi & Russell-Sewell, 2023; Vajapey et al., 2020).

The role of the educational environment in shaping IP is further evident in the variation of IP prevalence across academic years. While our subgroup analysis did not yield statistically significant differences, IP appeared to be highest among first-year students (45%) and lowest among those in their final years of medical school (31–37%). This pattern suggests that early-stage medical students may be particularly vulnerable, likely due to the transition into a demanding academic environment, unfamiliar expectations, and frequent evaluations. Indeed, multiple studies in this review have highlighted that IP is strongly influenced by competitive academic cultures, examination rankings, and fear of failure (Alzufari et al., 2024; Franchi & Russell-Sewell, 2023).

As students progress through medical training, the decline in IP prevalence may reflect the protective effects of increased experience, competence, and professional identity development. This aligns with longitudinal findings by Rosenthal et al. (Rosenthal et al., 2021), which reported significant decreases in IP scores over the academic year. However, the trajectory of IP is not uniform across all medical schools. In contrast to Rosenthal et al., Houseknecht et al. found that IP increased at the end of three years of medical school, suggesting that institutional or contextual differences may shape IP’s progression (Houseknecht et al., 2019). Furthermore, two studies in our review reported that as IP increased, professional identity declined (Houseknecht et al., 2019; Hu et al., 2019), reinforcing the idea that medical training may play a role in either mitigating or exacerbating impostor feelings.

Variations in IP prevalence due to institutional or contextual differences is further evident in the regional variations, with the highest rates observed in North America and Europe and the lowest in South America. These disparities may reflect differences in medical education systems, as medical training in North America and Europe is often characterized by rigorous academic competition and hierarchical learning environments, all of which may contribute to heightened impostor tendencies (Barron’s Educational Series, 2006; Craig et al., 2018; Rivera et al., 2021). Cultural differences, variations in mentorship structures, and differences in institutional expectations may also play a role in shaping impostor experiences across regions (Alsaleem et al., 2021; Franchi & Russell-Sewell, 2023; Sivananthajothy et al., 2024).

Despite multiple subgroup and sensitivity analyses, substantial heterogeneity persisted across studies, suggesting an underlying issue that extends beyond methodological variation. We attribute this to the limited conceptual clarity surrounding impostor phenomenon. As Gullifor et al. argue (Gullifor et al., 2024), the construct suffers from weak theoretical foundations, and fragmented, often atheoretical associations with related constructs across disciplines. This conceptual ambiguity has contributed to methodological stagnation. Most notably, the overreliance on cross-sectional survey designs among student populations, as reflected in our review, yields findings with limited depth or generalizability. Compounding this issue is the lack of consensus on how IP should be measured or what thresholds indicate meaningful severity. Indeed, the studies in this review utilized four different tools to measure IP, which was associated with signficiant differences in IP prevalences on subgroup analysis. Furthermore, the commonly used CIPS cutoff of 61, for example, was introduced by Clance without empirical validation (Clance, 1986), while Holmes’s alternative threshold of 62 is based on a validation sample of only 62 participants (Holmes et al., 1993). These definitional and measurement inconsistencies likely underlie the heterogeneity observed in our meta-analysis and highlight the pressing need for a theoretically grounded, psychometrically rigorous framework to advance IP research in medical education and beyond.

Overall, the high prevalence of IP among medical students carries significant implications for an already strained medical education system. Its strong association with anxiety, depression, and burnout can hinder student well-being and academic performance, as reported in several studies (Diaconescu et al., 2024; Elnaggar et al., 2023; Levant et al., 2020). Additionally, IP has been linked to a diminished sense of belonging and a decline in professional identity development (Houseknecht et al., 2019; Hu et al., 2019), both of which are crucial for fostering competent and confident future physicians.

To address IP within medical education, future efforts must begin with conceptual clarity. Without psychometrically sound tools and a unified framework for defining and assessing impostor phenomenon, both research findings and practical interventions risk being inconsistent or misdirected. Interpretation of existing data should therefore be approached with caution, and future research must prioritize the development of validated, theory-driven approaches to studying IP in medical education.

Limitations

This systematic review and meta-analysis has several limitations. Substantial heterogeneity was observed across studies (I² = 95.6%), reflecting variability in study populations, measurement tools, thresholds for defining IP, and institutional contexts. While subgroup and sensitivity analyses explored potential sources of this heterogeneity, much of it remained unexplained. This persistent variation likely reflects not only methodological differences but also deeper issues in the construct validity and operationalization of IP itself, which limits the generalizability and interpretability of pooled prevalence estimates.

Additionally, significant publication bias was detected (Egger’s test, P = 0.0081), raising concerns that studies reporting lower prevalence estimates may be underrepresented. However, as Borenstein explains in his work on meta-analysis (Borenstein, 2019), publication bias is primarily a concern when statistical significance determines publication likelihood, which may not directly apply to prevalence studies. Nonetheless, our results should be interpreted with caution, given the potential for overestimation.

Most included studies relied on self-reported, cross-sectional survey data, making findings susceptible to recall and social desirability bias, as well as limiting causal inferences and longitudinal insights. The geographic distribution of studies was also uneven, with a concentration in North America and Asia and limited data from Africa and Latin America, raising concerns about global representativeness. Finally, the widespread use of unvalidated cutoffs further complicates comparisons across studies and calls into question the precision of reported prevalence rates.

This meta-analysis establishes that impostor phenomenon is a highly prevalent concern in medical education. However, our most significant conclusion is that the quality of the evidence base does not match the scale of the problem. The profound heterogeneity, driven by inconsistent measurement, indicates that the term 'impostor phenomenon' may not represent a single, coherent construct in the current literature. Therefore, we argue that the priority for future research must shift from merely documenting prevalence to establishing construct validity. Only by building this methodologically sound foundation can we design interventions that genuinely support medical student well-being and professional identity formation.

CIPS

Clance Impostor Phenomenon Scale

Confidence Interval

GPA

Grade Point Average

HBCU

Historically Black Colleges and Universities

Impostor Phenomenon

LIS

Leary Impostor Scale

NOS

Newcastle–Ottawa Scale

PRISMA

Preferred Reporting Items for Systematic Reviews and Meta–Analyses

PWI

Predominantly White Institution

UiM

Underrepresented in Medicine

YIS

Young Impostor Score

Conflict of interests

The authors declare that they have no conflict of interest.

Ethical approval

Not applicable.

Consent for publication

Not applicable

Funding

No funding or sponsorship was received from any companies, groups, individuals, organizations, or any other entities.

Author Contribution

Study concept and design: YMO. Internet searching: YMO and YAK. Study selection: AE, AMZ, YM, and YMO. Data extraction: AE, AMZ, YM, and YAK. Quality assessment: AE, AMZ, YM, and YAK. Data analysis: AA. Drafting the manuscript: YMO, YAK, MM, and AA. Proofreading the manuscript: MEA.

Acknowledgments

The authors have nothing to acknowledge.

Data Availability

The dataset supporting the findings of this study are available from the corresponding author upon reasonable request.

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The Impostor Phenomenon Construct in Medical Education: A Meta-Analysis of its Prevalence and a Critical Appraisal of its Measurement

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Abstract

Figures

Introduction

Methods

Eligibility criteria and literature search strategy

Selection process and data extraction

Quality assessment

Data synthesis and Publication bias

Results

Search results

Study characteristics

Meta-analysis of Prevalence of Imposter Phenomenon

Overall Prevalence of Impostor Phenomenon Among Medical Students

Prevalence of Impostor Phenomenon by Sex

Prevalence of Impostor Phenomenon by Academic Year

Prevalence of Impostor Phenomenon by Region

Prevalence of Impostor Phenomenon by Tool

Prevalence of Impostor Phenomenon by Study Quality

Sensitivity Analysis

Narrative Synthesis of Correlates of Imposter Phenomenon

Impostor Phenomenon and Sociodemographic Factors

Psychological Correlates of Impostor Phenomenon

Academic Correlates of Impostor Phenomenon

Discussion

Limitations

Conclusion

Abbreviations

Declarations

Funding

Author Contribution

Acknowledgments

Data Availability

References

Additional Declarations

Supplementary Files

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