What do Immunology and Impostor Syndrome Have In Common?

As an Advanced Heart Failure and Transplant Cardiology Fellow this year, transplantation immunology is an important part of my curriculum. While I try to stay up-to-date on the latest advances in care in heart failure, cardiogenic shock, and mechanical circulatory support, I recently took a deeper dive into the fascinating history of organ transplantation and immunology – which brought me to Sir Peter B. Medawar, widely regarded as the “father of transplantation”.

Sir Peter Brian Medawar

Sir Peter Brian Medawar: https://www.thefamouspeople.com/profiles/peter-medawar-7366.php

Medawar was a Brazilian-born British zoologist who received (with Sir Frank Macfarlane Burnet) the Nobel Prize for Physiology or Medicine in 1960 for developing and proving the theory of acquired immunological tolerance. His early training and studies in England were focused in zoology and comparative anatomy, and his initial research was on connective tissue cells and tissue culture.

He became interested in skin grafting during World War II after witnessing military pilots sustaining severe burns in plane crashes and moved to Glasgow to continue this work for the Medical Research Council. Over the 1940s-early 1950s, he performed and published a series of experiments on the behaviors of skin autografts and allografts in burn victims. He demonstrated that skin allografts (i.e. homografts), although initially successful, were rejected within two weeks. In his experiments, when a second allograft from the same donor was attempted, the allograft was rejected much more quickly. Thus, he established the idea that allograft reactions were immunological. In the conclusion of their paper The Fate of Skin Homografts in Man, Gibson and Medwar state that “The time relations of the process, the absence of a local cellular reaction, and the accelerated regression of the second set of homografts suggest that the destruction of the foreign epidermis was brought about by a mechanism of active immunization.”

He furthered the ideas of genetically determined immunologic systems and immunologic tolerance through additional studies in different model organisms, including cattle and mice. In 1951, he tested the effects of cortisone on survival of skin homografts in rabbits and found that the daily subcutaneous administration of 10 mg cortisone acetate to adult rabbits delayed graft healing and vascularization and lengthened the life of skin homografts by 3x-4x!

Figure 3 from Billingham RE, Krohn PL, Medawar PB. Effect of Cortisone or Survival of Skin Homografts in Rabbits. Br Med J. 1951

Figure 3 from Billingham RE, Krohn PL, Medawar PB. Effect of Cortisone or Survival of Skin Homografts in Rabbits. Br Med J. 1951. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2068993/pdf/brmedj03547-0003.pdf

As excited as I was to read about this fascinating history of immunology and transplantation, I was even more interested to find that Medawar was a supporter of women in science (#HeForShe). In 1979, he published a book called Advice to a Young Scientist, a book he says is “the kind of book I myself should have liked to have read when I began research…” In the eight short pages of his book’s fifth chapter entitled “Sexism and Racism in Science”, he addresses the concepts of impostor syndrome, gender equality in academic medicine, and the frequent invisibility of women in science – all concepts still at the forefront of our current dialogue 40 years later.

Excerpt from Advice to a Young Scientist by Peter B. Medawar

Excerpt from Advice to a Young Scientist by Peter B. Medawar

The history of medicine is full of fascinating personalities and stories like this one, and to quote Medawar himself, “I do not know any scientist of any age who does not exult in the opportunity continuously to learn.”


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Feel Like An Imposter? Strategies For Dealing With Early Career Self-Doubt

As we were wrapping up our first editorial meeting for the AHA Early Career Bloggers on Saturday at Scientific Sessions 2018, the new bloggers were given this advice: “Over the next three days, do something [at Scientific Sessions] outside of your comfort zone.” This year’s Scientific Sessions offered some novel experiences –  augmented reality in the Cath Lab, network analysis for high throughput data, and machine learning for dummies. But the thing that made me the most uncomfortable was having my research recognized by my council.

If you have read my World AIDS Day blog, you know that most of my research and clinical work has been in the field of HIV. I came to the cardiovascular space out of necessity because my patients living with HIV were developing cardiovascular disease at higher rates than those without HIV. I never worked as a CICU nurse or in cardiac rehabilitation, and I still get confused about the many different types of antihypertensive medications. I could reasonably be considered a cardiovascular carpetbagger. Yet I work hard to understand cardiovascular science and practice guidelines because I know it is important to helping people living with HIV enjoy the healthiest life possible. Knowing this, about five years ago, my mentors pushed me to get more involved with the American Heart Association which has led me attend various AHA conferences, review abstracts, and apply for (and receive) AHA Research funding.

This year at Scientific Sessions, I was honored with the Council on Cardiovascular and Stroke Nursing (CVSN) Research Article of the Year Award. It is an incredible honor recognizing work that I am proud of. And while I am grateful to the CVSN and the sponsor for this award, my first thoughts after receiving the notification of award  were, “Wow, this is amazing,” quickly followed by, “Why me? Why an article on improving cardiovascular health in people living with HIV? Maybe they didn’t get other nominations.”  I felt undeserving and uncomfortable being honored for work I invested the last three years of my life in and I could not understand why.

Imposter Phenomenon, or Imposter Syndrome, first defined in 1979 by Clance and Imes, are feelings of fraudulence by high achievers who “do not attribute their success to their own abilities despite their many achievements and accolades.”  Recent research suggests most professionals can relate to these feelings, but it can be especially prevalent as new roles are taken on, especially in first jobs or new challenges. While Impostor Syndrome is associated with academic success, it is also associated with poor mental health outcomes including anxiety, depression, psychological distress, and minority student status stress.  There is also  evidence that Imposter Syndrome can make one reluctant to seek out new professional opportunities. Thus, Imposter Syndrome may be especially stunting to early career scientists and clinicians.

Strategies for Managing Imposter Syndrome

  • Recognize that many people have the same feelings of self-doubt at some point in their career
  • Talk about it and ask your trusted mentors and colleagues about their own feelings of being an imposter
  • Write down your strengths and how those led to your accomplishments
  • Develop a strong, safe social support network to share your feelings of self-doubt
  • Read about/listen to others talking about imposter syndrome, there are many great resources available which can help you contextualize your experiences
  • Be present for others who are going through similar experiences

The strategies for managing Imposter Syndrome are timeless but seem hard to achieve. A recent paper by Dr. LaDonna and colleagues in Academic Medicine suggests that having senior colleagues speak openly about their own experiences with self-doubt can have a positive effect. In addition to open discussion about self-doubt, is the importance of a strong support network the importance of perspective and reflection on their own strengths in order to expel “negative views of their own flaws”.

While such strategies may seem contradictory to social media which often highlights success but rarely failures, a recent twitter discussion on Imposter Syndrome (hosted by Emma Clayton of NHS Women Leaders) did just that. This discussion reveled many useful strategies and resources and created a space for people to share their experiences with imposter syndrome with others who had similar struggles. Emma is currently building a website designed to serve as a hub for women to come together and mentor each other as they seek new leadership roles, which should be up later this month.  In reading through her thread, I realized that my feelings of unworthiness can be a double-edged sword and that in the end I just need own it. I need to let my discomfort with my success drive me, not distress or diminish me; motivate, not isolate, me; and above all else,  never let it hold me back from confidently, passionately,  pursuing my goals.

As you reflect back upon your accomplishments in 2018, I hope that you have not feelings of being an imposter stop you from enjoying those successes or thwart progress toward your own goals. But if you are one of the many of us who have, this new year resolve to lessen the negative impact of the imposter and advance confidently in the direction of your dreams.

Photo by Paul Joyce on flikr