The need to change the culture in medical education, beginning in the classroom, has been recognized as an educational priority [1, 2]. Developing wellness and burnout prevention skills within curricula has also been identified as a necessary and required component of physician assistant (PA) education [3]. Similarly, the National Academy of Medicine National Plan for Health Workforce Well-being highlights academic institutions and medical training programs as key players to collectively foster the well-being of the healthcare workforce and improve the effectiveness of healthcare teams [4]. Recent curricular innovations involving mindfulness and decentering programs have effectively improved life satisfaction, lowered perceived stress, and increased psychological flexibility through increasing mindfulness ability within health professions education more broadly [5,6,7,8].

Although improving mindfulness may lead to improved outcomes associated with well-being, the underlying cause or risk factors associated with negative outcomes has yet to be fully understood and targeted through curricular intervention. Experiences that heighten stress in medical learners include unrealistic expectations, excessive harsh inner criticism, and unattainable goal setting, as seen with negative thought patterns common to maladaptive perfectionism [9]. These harmful cognitive patterns associated with maladaptive perfectionism have been identified as strong predictors of psychological distress in students within health professions education programs [10,11,12] and have critical implications for mental health and well-being. A secondary consequence of maladaptive perfectionism may be its impact on the development of an adaptive professional identity [2].

An academic orientation and mindset toward faultless performance begins in health science courses taught in high school and during undergraduate studies. During graduate training, however, this culture and mindset intensifies stress and increases the risk for burnout during didactic and clinical training, predisposing learners to the potential for early career burnout. Maladaptive perfectionism may lead to self-doubt and a defensive stance such as psychological inflexibility, lack of openness, receptivity, and creativity, and ability to problem solve effectively [13,14,15]. Driven by a fear of failure, maladaptive perfectionism, therefore, not only poses risk to student and clinician well-being, but also may reinforce an educational culture of perfectionism [9, 16, 17]. This cognitive mindset stands in contrast to adaptive forms of perfectionism, when students set high, yet attainable, personal standards that support high achievement and effective goal setting, perfectionism is considered adaptive [18].

Given the high academic expectations for achievement common to students aspiring to enter the health professions, it may not be a surprise that medical learners often report experiences of impostor phenomena [19]. Impostor phenomenon, characterized by pervasive feelings of inadequacy and self-doubt of one’s intelligence and skills, even in the presence of high, personal achievement [9, 20], is a normative process, especially during the didactic and clinical phase of health professions education, including PA education. Students often question their abilities, compare themselves to classmates and colleagues, and feel unease related to competence within their profession. While impostor phenomenon may be a common, often normalized experience, it also serves as a source of increasing stress within education. High levels of impostor phenomenon experiences are associated with increased risk of burnout, depression, and anxiety [21] and with increased risk of suicide [9].

In contrast to the cognitive patterns associated with maladaptive perfectionism, which may foster frequent experiences of impostor phenomena, the cognitive mindset involved in self-compassion may serve as a protective factor. Román-Calderón et al. [22] found that compassion and self-compassion act as protective factors against healthcare stress and burnout in medical students and physicians. Self-compassion allows an individual to be more accepting, offer themselves grace, recognize when judgement arises, and respond with less criticism and more tolerance of gaps between expectations and reality. It is the capacity to be gentle with oneself even during stressful and challenging moments [23, 24]. While healthcare providers are often known for showing and prioritizing compassion, self-compassion may not be a skill that comes as intuitively [25], and may not be acquired or practiced during education or training.

Related to the cognitive mindset of self-compassion is mindfulness, a multidimensional construct [26,27,28,29] that has been broadly linked to well-being, Baer et al. [30] identified five aspects or dimensions of mindfulness including Non-judgement, Observation, Description, Non-reactivity, and Acting with Awareness. Studies examining mindfulness in PA students support the important role mindfulness may play in fostering professional resilience [7]. Hoover et al. [5] demonstrated that changes in levels of mindfulness predicted changes in life satisfaction and perceived stress in PA students who received a curricular intervention designed to increase levels of mindfulness. Although mindfulness is associated with improved well-being, academic success, and professional resilience [5,6,7, 31,32,33,34,35], it is unclear what aspects of mindfulness may be more pertinent to the medical learner in terms of improving well-being.

The current study examined three specific research questions related to PA students at the start of their health professions education.

  1. 1.

    Do levels of maladaptive perfectionism and self-compassion explain levels of impostor phenomenon?

  2. 2.

    What aspects of mindfulness are most prominent in PA students at the onset of their training?

  3. 3.

    What aspects of mindfulness most strongly predict well-being in PA students at the onset of their training?

Materials and Methods

Participants

Three hundred fifty-one participants completed study measures for a response rate of 94.8% (351/370). Participants were PA students from six PA programs within publicly and privately funded institutions across the United States (Table 1). The mean age (25.89 years) and gender composition (20.8% male) approximate national demographic data from the Physician Assistant Education Association [36]. All measures were completed during the first week of PA training after matriculation.

Table 1 Survey response rate by PA program
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Measures

Demographic information was collected from participants and five validated instruments were administered to assess levels of maladaptive perfectionism, impostor phenomenon, well-being, mindfulness, and self-compassion.

Maladaptive perfectionism is a mindset characterized by rigid personal standards for constant perfectionism and harsh self-appraisal when unrealistic performance expectations are not met [11]. The Maladaptive Academic Perfectionism Scale (MAPS), designed to measure the construct in an academic setting, was used in the present study. The 10-item scale contains 5 items measuring emotional aspects of maladaptive perfectionism and 5 measuring behavioral aspects [37]. A sample item from the emotional subscale is, I constantly worry that I won’t do well on assignments. A sample item from the behavioral subscale is, It is not important if I make a mistake in my school work. Respondents used a 4-point Likert scale, with 1 representing strongly disagree and 4 strongly agree, to answer each item. Negatively worded items were reverse scored. Higher scores indicated lower levels of maladaptive perfectionism. The scale has demonstrated moderate internal reliability, low risk of social desirability bias, and high content validity in studies conducted among university students [37].

Impostor phenomenon (IP) represents a self-assessment of incompetence despite evidence to the contrary common among high achieving individuals [38, 39]. The 20-item Clance Impostor Phenomenon Scale (CIPS) was used in the current study to identify the presence of thoughts and feelings consistent with IP. A sample item is I often compare my ability to those around me and think they may be more intelligent than I am and response options were not at all true, rarely, sometimes, often, and very true. Higher scores indicated stronger experiences of IP. CIPS has demonstrated strong discriminant and construct validity and a high level of internal consistency [38]. All items are positively worded, decreasing the risk of social desirability [38].

The Five Facet Mindfulness Questionnaire (FFMQ-15) was used to measure five attributes of mindfulness: observing internal and external stimuli, describing one’s present moment experience, acting with awareness in the present moment, non-judging of one’s inner experiences, and non-reacting to one’s inner experience. A sample item from the observing subscale is When I take a shower or bath, I stay alert to the sensations of water on my body. A sample item from the describing subscale is I’m good at finding words to describe my feelings. A sample item from the non-judging subscale is I think some of my emotions are bad or inappropriate and I shouldn’t feel them (reverse scored). A sample item from the acting subscale with awareness is I don’t pay attention to what I’m doing because I’m daydreaming, worrying, or otherwise distracted (reverse scored). A sample item from the non-reactivity subscale is When I have distressing thoughts or images I am able just to notice them without reacting. Response options were along a 5-point Likert scale, with 1 indicating never or very rarely true, 2 rarely true, 3 sometimes true, 4 often true, and 5 very often or always true. Items indicating lower mindfulness were reverse scored and higher total scores indicated higher levels of mindfulness [33]. The FFMQ-15 has strong construct and convergent validity and has demonstrated sensitivity to change after psychotherapeutic interventions [40].

The 12-item short form of the Self Compassion Scale (SCS) was used to measure six factors of self-compassion: self-kindness, mindfulness, common humanity, self-judgment, overidentification, and isolation [41]. A sample item is I try to see my failings as part of the human condition and response options range from almost never to almost always on a 5-point Likert scale. Items measuring negative factors (self-judgment, overidentification, and isolation) were reverse scored. Higher scores indicate higher levels of self-compassion. Total self-compassion scores on the short SCS are strongly correlated with the long SCS [42], which has demonstrated both strong convergent and discriminant validity with other well-being indicators measured among university students [43].

The World Health Organization Five Well-Being Index (WHO-5) scale was utilized to identify self-reported levels of student well-being. A sample item is I have felt cheerful and in good spirits. Response options are on a 0 to 5 Likert scale, with 0 representing at no time, 1 some of the time, 2 less than half the time, 3 more than half the time, 4 most of the time, and 5 all of the time. The scale has demonstrated good construct validity in several populations, including young adults, university students, and research participants [44, 45].

Procedure

IRB approval (AZ #1011) at the primary institution included reliance agreements with all institutions involved. Each of the separate validated instruments and demographic questions were entered into a survey distribution platform (REDCap®) to create a single survey with a single link. This survey link was distributed by way of email using REDCap®. Participating programs offered the voluntary survey at the same time for all students in each program, during the first week of PA training after matriculation. There was no incentive to take the survey; however, approximately 5–10 min within class was provided for survey completion. The survey link included descriptions of the voluntary and confidential nature of the study. Statistical analyses to answer three study research questions were performed using R statistical software(version 4.3) [46].

Results

Do Levels of Maladaptive Perfectionism and Self-Compassion Explain Levels of Impostor Phenomenon?

To determine if higher levels of maladaptive perfectionism (MAPS) and lower levels of self-compassion (SCS) predicted variance in impostor phenomenon (CIPS), a linear regression was conducted in which MAPS and SCS served as predictors, controlling for age, with CIPS as the criterion. Results are presented in Table 4. This model explained 52.61% of the variation of CIPS (F(3, 323) = 121.7, p < 0.001)) with both MAPS (B = 0.52; p < 0.001) and SCS (B =  − 0.29; p < 0.001) significantly contributing to the prediction of CIPS.

What Aspects of Mindfulness Are Most Prominent in PA Students?

Descriptive statistics were calculated for each of the five aspects of mindfulness operationalized by the Five Facet Mindfulness Questionnaire (FFMQ) to determine the relative prominence of each component of mindfulness. These results appear in Table 2. During the first week of PA training after matriculation, PA students were highest in their ability for Non-judgement (x = 3.53), followed by Observation (x = 3.43) and Description (x = 3.35). Their relatively lowest levels were Non-reactivity (x = 3.17) and Acting with Awareness (x = 3.16).

Table 2 Level of each aspect of mindfulness at the start of PA education (N = 351)
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What Aspects of Mindfulness Most Strongly Predict Well-Being?

To determine what aspects of mindfulness are most relevant to predicting levels of well-being, a linear regression analysis was conducted. These results appear in Table 3. The model explained 24.62% of variance in well-being (WHO), (F(6, 331) = 19.35, p < 0.001). Of the five aspects of mindfulness, Non-judgement was the strongest predictor of well-being, (B = 0.31; p < 0.001), followed by Description (B = 0.16; p = 0.002) and Non-reactivity (B = 0.14; p = 0.009). Observation (B = 0.08; p = 0.097) and Acting with Awareness (B = 0.08; p = 0.120) were not significant predictors of well-being.

Table 3 Predicting WHO-5 (well-being) with FFMQ (mindfulness) subscales
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Discussion

Although there is growing consensus that wellness strategies should be incorporated early in the education and training of medical learners, knowledge of what strategies are most effective has yet to be adequately understood. To represent medical learners, our study examined PA student matriculants in one of six accredited PA programs across the country. The study aimed to examine potential underlying causes associated with negative outcomes in PA students to better inform and tailor curricular innovations with a goal of fostering professional resilience early on in training and education. Specifically, we explored the relationship between cognitive mindsets associated with maladaptive perfectionism and self-compassion in relation to impostor phenomenon experienced in PA students at the onset of their education and training. To expand existing knowledge and build on previous research that has established a strong relationship between mindfulness and well-being [47,48,49,50], our study examined the relationship among five aspects of mindfulness with well-being within a sample of PA students starting their education and training.

Do Levels of Maladaptive Perfectionism and Self-Compassion Explain Levels of Impostor Phenomenon?

Negative cognitive patterns common in medical learners such as maladaptive perfectionism and protective cognitive patterns associated with self-compassion were implicated in the level of experienced impostor phenomenon in our sample of PA students. Knowing the level of maladaptive perfectionism and level of self-compassion predicted over 50% of impostor phenomenon reported by PA students. These findings may reflect an underlying systemic culture problem in the health professions that begins in health education courses in high school through graduate and professional training. These findings are relevant to medical science educators because maladaptive perfectionism and impostor phenomenon have the potential to impact not only performance and skills acquisition during education and training, but the potential to impact professional identity development and future risk for burnout [8, 29]. More importantly, the findings also suggest that the negative impact of maladaptive perfectionism may be mitigated by developing capacities for self-compassion [51, 52]. Introducing self-care practices such as mindfulness may help with student and clinician well-being. Instilling an attitude and culture to reinforce self-compassion and dissuade maladaptive perfectionistic mindsets during education and training should be a priority of faculty and preceptors. These findings could be used to advocate for additional support at the institutional level to assist in reinforcing and cultivating different mindsets (Table 4).

Table 4 Predicting CIPS (impostor phenomenon) with SCS (self-compassion) and MAPS (maladaptive perfectionism)
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What Aspects of Mindfulness Are Most Prominent in PA Students?

Although the capacity for mindfulness has been viewed as a positive factor in many empirically examined outcomes, investigating specific aspects of mindfulness offers greater specificity in understanding its mechanism and the role it plays within different contexts and populations. We investigated five dimensions of mindfulness [35] to more specifically understand the adaptive role mindfulness abilities have for well-being in PA students:

  • ability for observing internal and external stimuli (Observation)

  • ability for describing one’s present moment experience (Description)

  • ability for acting with awareness in the present moment (Acting Awareness)

  • ability for non-judging of one’s inner experiences (Non-judgment)

  • ability for non-reacting to one’s inner experience (Non-reactivity)

Within our sample of PA students, Non-judgment of inner experience was the highest relative aspect of mindfulness reported by participants. This aspect of mindfulness reflects the tendency to approach one’s thoughts and feelings with a non-judgmental and accepting attitude, refraining from categorizing internal experiences as inherently good or bad. This suggests that PA students enter their professional education and training with a relative strength in the ability to experience thoughts and feelings without criticizing oneself for having them. The second highest facet of mindfulness reported by participants was Observation, indicating an ability to attentively notice both internal and external stimuli, including sensations, thoughts, and emotions, as well as elements in the immediate environment. Those adept in this aspect of mindfulness tend to exhibit heightened awareness of various aspects of their experience without becoming overly absorbed or entrenched in them. Both capacities are consistent with current expectations to perform well as a healthcare professional.

The two lowest relative aspects of mindfulness reported by PA students were Non-reactivity and Acting with Awareness. Non-reactivity to inner experience is the capacity to regulate emotions and thoughts without succumbing to impulsive reactions or yielding to urges to act reflexively. Individuals proficient in non-reactivity observe thoughts and feelings objectively, choosing intentional actions. This cultivates emotional consistency and resilience, particularly in high-stakes or emotionally charged situations. Lower relative ability in this domain would suggest greater risk for errors that could exacerbate tendencies for maladaptive perfectionism and impostor phenomena experiences that impact learning during education and training. Acting with awareness in the present moment signifies the capacity to fully engage in an activity or moment, free from distractions, and avoid mechanical execution of tasks. Comparable to being “in the zone” or synchronized with one’s actions, it emphasizes purposeful and intentional engagement and the ability to prioritize being present in experience over attending to associated thoughts, sensations, or feelings. This relatively lower capacity in PA students may speak to their ability to engage effectively in active listening and patient-centered and collaborative patient care models. If the goal of well-being and professional resiliency initiatives is to target improvement in aspects of mindfulness that are least developed, the greatest opportunity may be in Non-reactivity and Acting with awareness.

What Aspects of Mindfulness Most Strongly Predict Well-Being?

Although many aspects of mindfulness may be important, the component of mindfulness most predictive of well-being in our PA student sample was non-judgment, suggesting that the ability to experience thoughts and feelings without self-criticism is most associated with well-being of PA students and medical learners more broadly. Description and non-reactivity were the only other two significant predictors of well-being, indicating the relative importance of the two aspects of mindfulness in the well-being of PA students. Description denotes the ability to express one’s feelings, thoughts, and experiences in words with precision. Individuals proficient in description can effectively articulate their inner experiences, fostering enhanced self-awareness and a deeper understanding of moment-to-moment mental states. Non-reactivity, on the other hand, refers to the capacity to regulate emotions and thoughts without succumbing to impulsive reactions or yielding to urges to act reflexively. This capacity allows individuals to observe thoughts and feelings objectively and choose intentional actions.

Profile of the Well-Adjusted Medical Learner

The profile of the most well-adjusted student learner is someone who approaches their thoughts and feelings with a non-judgmental and accepting attitude, refraining from categorizing internal experiences as inherently good or bad. They can experience thoughts and feelings without being self-critical (non-judgement). They are also able to express their feelings, thoughts, and experiences in words with precision and effectively articulate their moment-to-moment mental states (description). The well-adjusted learner has the capacity to regulate emotions and thoughts without succumbing to impulsive reactions or yielding to urges to act reflexively. They respond to feelings and thoughts by acknowledging them without needing to react; this allows space for intentional actions rather than reactions (non-reactivity).

PA students enter their education with relative strengths in non-judgement and description, ranked first and third respectively. With non-reactivity significantly associated with well-being but not relatively high in matriculating students, there is an opportunity for faculty and program administrators to cultivate this ability in students to enhance resiliency early in education and training. Interestingly, acting with awareness was the lowest relative ability in PA students and was also found to be the least related to well-being. When determining what aspects of mindfulness ability to address through curricular innovation, faculty and program administrators may consider committing less allocated time and resources to developing the ability to be present in moment-to-moment experience (acting with awareness) if supporting overall well-being in the student learner is the primary aim of programmatic initiatives.

Strengths and Limitations

The inclusion of a geographically diverse sample, high survey response rate, and the use of validated instruments to assess study constructs offer validity to study findings. The exclusive use of self-report measures, however, is a potential limitation. Despite the high response rate, some degree of self-selection bias is also possible in that individuals who chose to participate may have differed in some way from those who chose not to participate. Additionally, this study only examined data from one time point, at the start of PA education, and therefore cannot infer with certainty that these findings would remain consistent with those at time of graduation or into their professional careers. Finally, demographic factors such as race and ethnicity that have the potential to influence constructs like impostor phenomenon were not assessed. Expansion of demographic data, to include factors such as race, ethnicity, and other aspects, along with inclusion of multiple time points to assess change score are possible areas for future research. This avenue for future research may provide avenues for more precise understanding within specific groups, such as differences related to gender [53], assisting educators in the development of targeted strategies to promote student wellness as learners experience the demands of PA education and the practice of medicine.

Conclusion

Healthcare worker burnout and well-being have been linked to risk of medical errors, compassion fatigue, and issues with workforce retention [54,55,56,57,58]. Learning more about the mechanisms through which mindfulness supports well-being and the cognitive patterns that mitigate professional identity formation such as impostor phenomenon can revolutionize existing practices within medical education and practice.

From our study, the aspect of mindfulness reported to be one of the lowest in PA students starting their education and training was non-reactivity. Interestingly, this ability was one of three that were significantly associated with well-being. The capacity for non-judgement explained for the greatest variance in well-being, suggesting that the ability to experience thoughts and feelings without criticizing oneself for having them is instrumental for well-being in PA students and potentially medical learners more broadly. These findings provide direction to faculty on how to direct resources to cultivate wellness within the classroom and to foster professional resilience in future medical professionals.

Our findings also revealed that levels of maladaptive perfectionism and self-compassion were highly predictive of impostor phenomenon. Through mentorship of future healthcare providers, educators can support students in recognizing the negative implications of harsh internal dialogue and self-judgement. Additionally, wellness curricula can effectively highlight the potential protective benefits of a mindset that adopts and values self-compassion. In doing so, educators have an opportunity to transform the culture in which medical student learners acquire knowledge, skills, and professional identity.