Are you an Imposter of Your Authentic Best Self?

Are you afraid that people important to you will find out that you're not as capable as they think you are?

As someone who has changed career path every 7 years over the last 30, I have appreciated feeling like an imposter on numerous occasions: as an intensive care and obstetrical nurse in the USAF, as an internal medicine nurse practitioner (NP), as a manager, emergency medicine NP, as a family practice NP, and most recently as an entrepreneur starting a coaching practice (while becoming a kundalini yoga instructor and a Reiki practitioner). My love of learning earned me a string of new degrees and certificates in order to gather skills to fit in. When I first became an NP 22 years ago, I shunned the idea of therapeutic touch, in lieu of learning medicine; and interestingly, as I was learning Reike this past weekend, I chuckled that I was feeling inadequate at something that is considered impossible to do wrong. Sometimes you have to get out of the way of yourself, so you can be yourself.

 Up to 70 % of successful people in the USA may have impostor feelings (Clance, 2001).  Imposter phenomenon was initially thought to be more prevalent in women, however more recent studies have shown less marked gender differences (Seritan & Mehta 2015). While it can drive superior achievements, it can be associated with counterproductive behaviors such as maintaining a low profile, self-sabotage, micromanagement, procrastination and acting out (Seritan & Mehta 2015).  Individuals with impostor phenomenon are at risk for persistent workaholism, burnout, anxiety, and depression, including suicidality (Seritan & Mehta 2015).  From the institutional standpoint, those with impostor feelings can have difficulties leading teams due to their inability to delegate due to the tendency to micromanage and set impossible goals for their teams. They may catastrophize, need to plan for all possibilities, have difficulty finalizing decisions, and lower other employees’ moral.  Clinicians with the impostor phenomenon may rely heavily on consultants due to self-doubt about the management of clinical cases, which may contribute to poor patient outcomes (Seritan & Mehta 2015).  Perfectionism partially overlaps with impostor characteristics however perfectionists feel validated by achieving their goals, while those with impostor phenomenon are less able to internalize successes. 

The flip side of Imposterism is Presence (Cuddy, 2015).  Presence is the state of being attuned to and able to comfortably express our true thoughts, feelings, values, and potential.  Presence is both about showing up and how you show up.  Behaviors shape attitude, more than attitude shapes behavior and small successes in managing behavior beget larger ones. Challenging situations are healthy because they offer opportunities to demonstrate acts of courage, which can be built on with each new challenge.   According to Cuddy (2015) when workers begin their work tasks thinking about their individuality, or start a job describing their true self or individuality, they are more attentive, connected, focused, happier, and perform better and make fewer errors.  Physicians are predisposed to burnout due to internal traits such as compulsiveness, guilt, and self-denial, and a medical culture that emphasizes perfectionism, denial of personal vulnerability, and delayed gratification (Gazelle 2015). Coaching has been demonstrated to be supportive for fatigue, low sense of accomplishment, self-doubt, compromised relationships, cynicism, decreased sense of purpose and inattention to personal health.

Are you afraid that people important to you will find out that you're not as capable as they think you are?

You can test yourself here:

Cuddy (2015) recommends “acting” with presence in order to change one’s mindset.  The power pose allows you to be the best version of you.  Don’t just fake it till you make it, fake it until you become it!  Breath in and out slowly and deliberately. Keep your shoulders back so that your chest remains open. Keep your chin up but not in a way that makes it look like you are looking down on others. Use deliberate motions when speaking. When stationary, keep your feet grounded. Beyond taking up physical space you should also take up “temporal space” or time itself. Feeling like you have to rush you might seem like you want to escape from the situation you are in and this is not a good presence. When you make a mistake don’t follow that up with collapsing inward.

Seritan & Mehta (2015) recommend:

Strategies for individuals:

Develop self-awareness regarding impostor phenomenon and associated behaviors (i.e., hiding out)

Practice accepting compliments graciously

Write down the steps you took to earn the success you achieved

Keep a record of positive feedback/evaluations you received

Celebrate accomplishments

Create a supportive mantra for yourself

Recall the people you think you “have fooled,” practice telling them how you tricked them, and imagine their response

Seek mentors and sponsors

Consider individual/group psychotherapy

Strategies for institutions:

Provide educational workshops on impostor phenomenon

Develop mentorship programs

Design targeted support and mentorship programs for international medical graduates and underrepresented minorities in medicine

Offer leadership training and coaching

Foster a culture that does not punish mistakes


Coaching can increase self-awareness, align personal values with professional duties, focusing on strengths, questioning thought patterns and beliefs, promote resilience, and provide a supportive partnership (Gazelle 2014).  

Clinician concerns and sample coaching questions:

Fatigue, low sense of accomplishment: “The demands on my time are too much; I’m exhausted and not accomplishing anything.”

Sample coach questions: “What’s another way of looking at this?” “What’s a new viewpoint?” “Will you start a ‘got-done’ list? Nightly, write down three things that went well.”

Self-doubt: “I should be smarter and more efficient. I don’t have what it takes.”

Sample coach questions: “I’m hearing a ‘not-good enough’ message. How are you experiencing this right now?” “If we could wipe the slate clean, what would you do differently going forward?”

Compromised relationships: “I get angry with staff and sometimes lose it. We’ve worked together for years; I don’t know what gets into me.”

Sample coach questions: “I hear disappointment in yourself.” “What happens physically just before you lose control?” “When you experience this, is there another response?”

Cynicism, decreased sense of purpose: “I’m like a hamster on a wheel. Why go on?”

Sample coach questions: “What gives your work value and meaning?” “What energizes you?”

Inattention to personal health: “I’d feel better if I played tennis regularly, but I never do.”

Sample coach question: “Will you put tennis on your calendar twice this week?”

Joyce M. Roché (2013) suggests interventions for imposter syndrome, which include: Take a hard look at your work habits. Learn to internalize external validation. Turn like-minded people into allies. Don’t suffer in silence. Look in an accurate mirror. See others objectively. Look at your fear. Take stock of your success. Have a sense of humor. Find the life you really want.  One of her tools for imposter syndrome is to write a letter to your younger self.

Dear younger Michelle,

I know that you strive to be more all the time because you have not felt that you are enough.  Listen to your heart.   Know deeply that you are indeed enough.  You do not have to be the best, just show up.  You do not have to be the most therapeutic, just listen. You do not have to keep doing, you are allowed to just be here now. Embrace your quirky, and sometimes intense, personality.  Your tribe will find you.  Stay creative and love what you love.  Keep learning and growing, and enjoy your spirituality as you find it.  Be compassionate not just to everyone around you, but also to you.  Use your fatigue to energize you, challenge your self-doubt with awesome coaching questions, listen deeply to those around you (especially when you disagree), find value and meaning in each moment, and get out there and run, wiggle and chant to your hearts content.  You are loved and you are love. Be the change you want to see in the world. 

Peace to all, love to all, light to all, and note to self for all,

Shelby (AKA “Big Michelle”)



Clance (1985) The Impostor Phenomenon

Amy Cuddy (2015) Presence: Bringing Your Boldest Self to Your Biggest Challenges

Cuddy, A (retrieved January 19, 2016) Power Pose

Cuddy, A (retrieved January 19, 2016) Presence: Bringing Your Boldest Self to Your Biggest Challenges

Gazelle et al.:(2014) Physician Burnout: Coaching a Way Out JGIM 

Roché, JM (retrieved January 19, 2016)

Roché, JM (2013) The Empress Has No Clothes: Conquering Self-Doubt to Embrace Success

Seritan AL. Mehta MM. (2015) Thorny Laurels: the Impostor Phenomenon in Academic Psychiatry Acad Psychiatry

From Infinity to Beyond

2015 is the year of infinity (2+1+5=8 or infinity)

As we move from this moment in 2015 to the next in 2016, we are reflecting on “what is happening now?” to “what wants to happen in the future “now”?”

We are always “becoming,” but somehow moving from one year to the next feels almost superstitiously significant.  I recall a friend telling me that whatever one is doing at the New Year, they would be doing for the rest of the year.

This year, I am becoming a Kundali yoga instructor; I even have a new name: I am Onkarprem Kaur.  In my new identity, I am embracing that “Love is the experience of selflessness within the self.” Kundalini yoga is known as the yoga of awareness, which incorporates components of pranayama (breathing exercises), kriyas (physical postures), meditation, mantras, chanting & deep relaxation to connect practitioners with their higher state of consciousness. My ego or my “mind-made self” has been triggered by each class, and I am discovering firsthand Einstein’s teaching that Ego=1/Knowledge. After teaching my first class, I was criticized for the same amount of time as I had taught. I found myself ready to quit the program, walking barefoot dressed in white linen around Boston, listening to “Back in Black” full blast, while dropping the F-bomb. Not my highest self.

Just as the reptile vigorously defends its territory, clinicians can emphatically defend their assumptions, diagnoses, and self-esteem. Egoism puts the clinician before the patient.  Self interest converts the patient or a coworker into an inconvenient irritant.  

Approximately 80% of medical errors are due to human errors.  These errors are due to self-interest. Our brain has two control centers: the automatic or reptilian brain, which processes stimuli in nanoseconds and which reacts instantly and emphatically; and the conscious brain which generates our higher self, our true unlimited potential.  

In “Medicine, Mistakes, and the Reptilian Brain: The NewMind Response to Better Decisions,” John Mary Meagher (2011) attributes errors in medicine to three major causes: haste, apathy and egoism. Haste includes convenience, stress, irritability, emphatic expression and impulsivity. Apathy includes labeling (stigmatizing), fatigue, stress, convenience and irritability. Egoism includes irritability, convenience, emphatic expression and labeling.

As we move from infinity (2015) to beyond, we can use ego and irritability as a vital sign to indicate that something is amiss. What is your irritability barometer?

1) List irritations that occur at home & work

2) Match the responses to the irritations (Neutral, mild, moderate, severe)

3) Monitor the responses over time

Use the "irritant" on the x-axis and grade your irritability response to the irritant as neutral, mild, moderate or severe on the y-axis.

Neutral response: Respond with humor or view the irritant from three months into the future

Mild irritability: Begin to blame, criticize or dislike/ any one or anything, or to sigh, roll the eyes, and become sarcastic.

Moderate irritability: To look at the time, to quicken one’s pace, to interrupt, to be preoccupied with formulating a response; to change one’s voice pitch or tone, to tighten one’s jaw or paw; to lean forward in one’s chair, and movements to become jerky.

Severe irritability: One’s voice becomes edgy-growling, one’s breaths quicken, one doesn’t listen, one talk over the other person. Regardless of what is said, one takes the opposite point of view. One squirms, sweats, changes stance, has the urge to stand up and show the patient the door.

Ask yourself the following questions: Am I more irritated? Am I labeling or stigmatizing? Is this way more convenient for me? If Yes, Ask Why?

Am I open to challenging data? Am I looking at the time? Would I like to be tended to as I am tending now?  If No, Ask Why?

Why? (Haste, Fatigue, Egotism, Doubt)

Haste: Am I rushed? (Antidotes: Not so fast, think first. Guessing is foolish.)

Fatigue: Am I tired? Am I apathetic? (Antidote: Rest. I am not helpless. I can make a difference.)

Egotism: Am I worried about my self-image? (Antidote: I am being paid to tend the patient, not my self image.)

Doubt: Am I harboring doubt about my thoroughness, knowledge, competence, conclusions? (Antidote: Doubt is your last chance to correct. Obtain help when needed. Reassess.)

Meagher (2011) encourages us to ask: Would I like to be treated as I am treating this patient? Who does this thought or action serve, the patient or me?

In contrast to egoism which pretends all that we are, humility prioritizes the patient and allows us to speak truth to the tyrants, both within and without. The humble person is empowered to advocate and to speak authentically.  The correct action is often inconvenient, and stellar action is always inconvenient.

I was worried about my self-image as a teacher.  My self-doubt allowed me to correct my course of action. In a short speech to the group, I was able to calm my inner bully, find my authentic voice, humble my ego, and to maintain both my dignity and that of my fellow students and my teachers. Not stellar, but good enough. My 40 day self-assigned kriya homework is designed to let go of my ego, now I will have to think more about why I am blogging about ego. The learning continues.... 

Are You Brave, or are you Reckless?

If you can sit quietly after difficult news; if in financial downturns you remain perfectly calm; if you can see your neighbors travel to fantastic places without a twinge of jealousy; if you can happily eat whatever is put on your plate; if you can fall asleep after a day of running around without a drink or a pill; if you can always find contentment just where you are: you are probably a dog. ~ Jack Kornfield

Are You Brave, or are you Reckless?

What makes a healthy individual?  Healthy is usually defined as a lack of something –an absence of overt physical /mental disease.  More recently “subclinical’’ markers or vulnerabilities for future disease have been identified in humans (i.e. pre-diabetes, metabolic syndrome, etc).  The focus on stress as a disease, has hindered progress in understanding how stress responses fit into the normal physiology of a healthy individual.  Romero et al (2015) are developing mathematical models to predict vulnerability and ask important questions:  Does the stress phenotype change across life history, across the day or over the course of the lifespan, and if so, why? Why are some individuals more likely to progress to stress-related disease than other individuals? What underlies the individual variation in the consequences of stress responses? How long must measures be at a certain level before we define them as exhibiting a stress phenotype? How does natural selection act on the stress phenotype?  

The constantly changing healthcare environment is ripe for determining factors that contribute to stress resilience.  Novelty seeking may be disproportionately represented among certain populations in healthcare (emergency room physicians, surgeons, etc) that our society views as altruistic and heroic. Mujica-Parodi et al (2014) demonstrated a fine line between individuals who are “brave” and those who are “reckless.” The brave feel fear but nonetheless overcome it. The reckless fail to recognize danger. Those who fail to recognize risk are less likely to mitigate it. From a clinical perspective, it matters not only whether an individual avoids or embraces risk, but also whether the response to risk is adaptive or maladaptive.  The most well educated student is not the one with the highest scores on standardized tests, but the one who is positioned to create successful interactions with complex, variable, and unpredictable environments (Gerdes 2015).  Adaptive clinicians both accurately recognize risk and avoid being paralyzed by fear.

If vulnerability and prediction of responses to future stressors could be incorporated into conceptual models of stress, a better concept of health and disease might arise.  The physiological and behavioral responses to stressors are critical mechanisms of resilience for healthy organisms. Sterling and Eyer (1988) defined allostasis as “stability through change,” which contrasts with the idea of homeostasis, or “stability through constancy.”  Allostasis is a paradigm for physiological regulation consistent with evolutionary theory.  In contrast to homeostasis, allostasis recognizes change, not constancy as the norm.  Success is defined as fitness in the context of complex natural context.  Geodes (2015) notes that education with this framework could lead out the full potentiality of learners, to support their successful engagement with complex, changing, and unpredictable environments.  

Psychologist Kelly McGonigal (2015) shares a simple and effective mindset intervention.  Simply knowing that stress is what arises when something one cares about is at stake, and that stress and meaning are linked leads to more positive outcomes. Both "we don’t stress out about things we don’t care about"and "we can’t create a meaningful life without experiencing stress". 

Like a self fulfilling prophesy,  when stress is viewed as inevitably harmful and something to avoid, one becomes more likely to feel doubt about their ability to handle challenges, alone in suffering, and unable to find meaning in struggles.   Stress is most likely to be harmful when one feels inadequate to it; becomes isolated from others; and feels meaningless and out of control. 

In contrast, accepting and embracing stress can transform these states into a totally different experience. Self-doubt is replaced by confidence, fear becomes courage, isolation turns into connection, and suffering becomes meaning—all without getting rid of the stress.

Viewing the stress response as a resource works because it helps one to believe “I can do this.” This belief is important for both ordinary and extraordinary stress. Seeing the upside of stress is about choosing to see how stress can help meet challenges in life which can influence long-term outcomes, such as health, happiness, and longevity.

Effective mindset interventions have three parts: 1) learning the new point of view, 2) doing an exercise that encourages to adopt and apply the new mindset, and 3) providing an opportunity to share the idea with others.  

McGonigal (2015) offers the following Stress Mindset Tools/exercises:

“One of the best ways to notice, value, and express your own growth is to reflect on a difficult time in your life as if you were a journalist writing a restorative narrative. How would a storyteller describe the challenges you have faced? What would a good observer see as a turning point in your story— a moment when you were able to reengage or find meaning? If a journalist were to follow you for a week, what evidence would the journalist see of your strength and resilience? What do you do that demonstrates your growth or expresses your values? What would friends, family, coworkers, or others who have witnessed your journey say to describe how you have changed or grown? What objects in your home or office would a photojournalist want to photograph as evidence of your growth or resilience?”

“Bring to mind a stressful experience from your past in which you persevered or learned something important. Think about what that experience taught you about your strengths and how to cope with stress; set a timer for fifteen minutes and write about the experience, addressing any or all of the following questions.  What did you do that helped you get through it? What personal resources did you draw on, and what strengths did you use? Did you seek out information, advice, or any other kind of support? What did this experience teach you about how to deal with adversity? How did this experience make you stronger? Now think about a current situation you are struggling through. Which of these strengths and resources can you draw on in this situation? Are there any coping skills or strengths you want to develop? If so, how could you begin to do so using this situation as an opportunity to grow?  Choose an ongoing difficult situation in your life or a recent stressful experience. What, if any, benefits have you experienced from this stress? In what ways is your life better because of it? Have you changed in any positive ways as a result of trying to cope with this experience?”



Gerdes et al (2015) A groundwork for allostatic neuroeducation

McGonagle, K (2015) The Upside of Stress

Mujica-Parodi, LR (2014) The fine line between ‘brave’ and ‘reckless’: Amygdala reactivity and regulation predict recognition of risk

Romero et al (2015) Understanding stress in the healthy animal –potential paths for progress

Sterling,P.,and Eyer, J.(1988).“Allostasis:a new paradigm to explain arousal pathology,

Moving from “WTF” to QFT (Question Formulation Technique)

I have been creating my own personal burnout, and I am ready to stop.  

When I get into a funk, I ask “Why don't they create a better_________?”  In this space, I am at the effect of “them” in hopes that “they” will fix something for me, because I am not happy! Indeed, I can get %$#%^ing angry at “them.” In this space, if I manage to accomplish anything, my energy seems to suck the life out of the room.  

In contrast, when I am on my game, I ask “Why don't I create a better_________?”

I have been stuck in my own ego, trying to solve problems in health care.  As I have been trying to figure out my coaching niche, I have been trying to be and do “more” at work.  On one hand, I know that we are all perfect, and on the other, I struggle with the “right” evidence-based answers to solve challenges confronted in healthcare. 

This week, I was leading a quality improvement project around medication refills and my tentative project was challenged by a fellow clinician’s criteria that we “Get to know patients.”  I watched my ego ask “how are we going to measure that?” as I stood on my chair writing down her idea on the white board.  My higher self came online within seconds to ask everyone to come to the board to write down their ideas, and to vote.  The next day as I researched how to empower patients to ask questions, I found great resources that are useful in for individuals of all ages, in all socioeconomic statuses and which have tested in community health centers, like the one in which I work.  I felt that I struck gold with the QFT (Question Formulation Technique). 

Since I finished my coaching program last year, I have been wanting to teach both clinicians and patients coaching skills, because the skills were life changing for me.  Unfortunately, I was not sure that my N=1 study would be well received by my fellow scientific clinicians.  I have been researching coaching in healthcare for months and finding lots of supporting data, and yet I have been “stuck” for months.  I have been frenetically NOT getting ideas out of my head (and I overloading my hard drive with research on the subject).  I have been trying to figure out the “right” questions in healthcare, rather than trusting each individual to determine their own best questions.

A beautiful question is an ambitious yet actionable question that can begin to shift the way we perceive or think about something, and that might serve as a catalyst to bring about change (Berger, 2014).  Our opportunity is to search for a question that is both hard and interesting enough that it is worth answering, and easy enough that one can actually answer it.

Last year, my husband and I transitioned out of jobs in the emergency department with the highest (65%) incidence of burnout, and we have settled into jobs in the 2nd/4th place (50%) in internal medicine/family practice.  We utilized coaching skills to place ourselves 7 miles from the ocean.  This gig is not one that gets much sympathy from our previous coworkers.

My challenge has been my ego trip of wanting to be more than I am, in being a part of something that is bigger than me.  I have been “Purposefully Becoming”  to realize the value of creating synergy in healthcare and to trust coaching principles:

    Each one of us is a perfect unique energy force

    The answers to all questions lie within

    There are no Mistakes

    Each moment describes who you are, and gives you the opportunity to decide if that's who you want to be

I want to create a space for us to ask our own powerful questions & create our own growth, so that we can be be more together, than we could be separately. 

Burnout is associated with emotional exhaustion, depersonalization and low sense of personal accomplishment.  Montero-Marín, et al (2011) differentiates it further into 3 types: frenetic, under-challenged, and worn-out.

The “frenetic” type of burnout describes involved and ambitious individuals who sacrifice their health and personal lives for their jobs and experience exhaustion.  High demands and low autonomy in the workplace increase exhaustion levels, especially in individuals with poor time management skills and a low level of resources.  Individuals experiencing frenetic burnout can benefit from interventions directed at reducing activation, removing accumulated tension and preventing exhaustion; improvement in time management to satisfy personal needs; and development of self-assertion and place limits on the acceptance of responsibilities. Thoughts that arise with frenetic burnout: “I think the dedication I invest in my work is more than what I should for my health.” “I neglect my personal life when I pursue important achievements in my work.” “I risk my health when I pursue good results in my work.” “I overlook my own needs to fulfill work demands.”

The under-challenged type describes indifferent and bored workers who fail to find personal development in their jobs.  They carry out tasks in a superficial manner, leading to feelings of meaninglessness and lack of personal development. It has been associated with cynicism,  boredom, indifference and a mechanical performance.  They lean toward passive coping skills, and may benefit from interventions that encourage interest, satisfaction and personal development through training of conscious attention towards tasks and through the establishment of challenging and significant targets. Thoughts that arise with under-challenged burnout:  “I would like to be doing another job that is more challenging for my abilities.” “I feel that my work is an obstacle to the development of my abilities.” “I would like to be doing another job where I can better develop my talents.” My work doesn’t offer me opportunities to develop my abilities.”

The worn-out type optimizes rewards by reducing efforts through 'neglect' of responsibilities and chooses this as a consequence of the defencelessness learned in the their experience with the organization. This neglect is the opposite of commitment and is associated with the perception of lack of efficacy in the carrying out of tasks. They feel they have little control over results and and that their efforts go unacknowledged. The worn-out subtype presents a profile of passive coping that could benefit from interventions directed at treatment for despair and increased confidence through the regaining of control and the perception of self-efficacy.  Thoughts that arise with worn-out burnout: “When things at work don’t turn out as well as they should, I stop trying.” “I give up in response to difficulties in my work.” “I give up in the face of any difficulties in my work tasks.” “When the effort I invest in work is not enough, I give in.”

An imbalance between effort and gratification is an important source of stress. When we shift to minimum performance, and minimum standards of working, rather than performing at our best, we make more errors, become less thorough, and have less creativity for solving problems. We make a difference, but not the difference that we would chose to make as our best selves. 

In contrast, reciprocal relations is essential for the health and well-being of individuals. Fortunately, each moment describes who we are, and gives us the opportunity to decide if that's who we want to be.  Each question we ask ourselves and one another, gets us closer to being our best selves.  Peer coaching has one of the strongest correlations to team effectiveness compared to any other team intervention (Hackman & O’Connor, 2005) and by using the Question Formulation Technique, we can coach ourselves and one another away from complaints and questions like “Why don't they______?” to empowerment & “Why don't I(we)______?”



Question Formulation Technique (QFocus) Coaching Tool:

1.  Determine your Question Focus: a stimulus or a springboard to use to ask questions (i.e.  a topic, image, phrase or situation) that serves as the “focus” for generating questions. An effective QFocus should be clear, should provoke and stimulate new lines of thinking and should not be a question.

2. The Rules for Producing Questions – Each of the four rules supports a behavior that facilitates effective question formulation.

  1. Ask as many questions as you can
  2. Do not stop to discuss, judge, or answer any questions
  3. Write down every question exactly as it is stated
  4. Change any statement into a question

3. Produce Questions- Use the Question Focus to formulate as

many questions as you can. Ask all kinds of questions about the topic, phrase, image, situation, etc. presented. (Make sure to follow the rules to allow yourself to think freely without having to worry about the quality of the questions you are asking.)

4. Improving the Questions – Once you have a list of questions, the next step is to learn about two different types of questions you might have on your list: closed-ended questions– questions that can be answered with a “yes” or “no” or with one word - and open-ended questions –questions that require and explanation.

This part of the process develops as follows:

First, please review your list and identify the closed-ended questions with a “C”and the open-ended with an “O.”

Second, think about and name the advantages and disadvantages of asking each type of question. You will see that there is value in asking both types of questions.

Third, practice changing questions from one type to another. Changing the questions will help you learn how to edit your questions to meet your purpose.

5. Prioritizing Questions – You might have a lot of questions on your list. It will be easier to work with the questions if some priorities are established. You will now choose three questions based on actions you want to take. For example, three most important questions, three questions you would like to address first, three questions you want to explore further, etc. After choosing the priority questions your next step is to name a rationale for choosing.

As a last step in prioritizing, please pay attention to the numbers of your priority questions. Are your priority questions at the beginning, in the middle or at the end?

6. Next Steps – Your questions can now be put into action. You might already have criteria on what to do with the questions. For example, you may use the questions to do research, develop a project, use the questions as a guide, etc.

7. Reflection – This is the last step in the process. It is now time to reflect on the work you have done: what you have learned and how you can use it. The reflection helps internalize the process, its value and how to apply it further.

Question Formulation Technique Coaching Tool (synergize burnout to opportunity):

1. “I am feeling both overwhelmed and stuck, and am not working to my full potential of helping myself or others professionally”

2. How do I become healthier? How do I stop feeling both overwhelmed and unproductive? How do I help all of healthcare create well-being? How do I create a business that thrives? How do I work within all of my communities so that both they and myself thrive? How do I stay in the moment? How do I manage my time wisely? How do I live a purposeful life? How might I be more with less effort? How might I educate people about questions? How do I help people help themselves? How do I empower others? Why is there a horizontal violence and bullying in healthcare? What if we could get rid of these toxic phenomenon? How might I use every moment to improve the work environment in healthcare in the care of myself and my communities? How might I create synergy with those around me to improve our well-being? Why is there burnout in healthcare? What if we could get rid of burnout and bullying and and create opportunity? How can we use each moment to improve my and my community’s well-being?

3. My “Why?, What if?, and How?” questions:

Why do I feel burned out? What if I could convert my feelings of burnout to well-being and become more productive (both personally and professionally)? How do I create synergy and spread that kind of energy?

My rationale: useful for “both me and we”

4. My tendency is to stay in the open ended question. To close them, I ask “Can I blog on this?” Do I know what well-being means for me? Do I appreciate both closed and open questioning?

5. Priority: Get out of my own head and out to people I care about.  Ironically, I am developing a theoretical framework applies research from psychology, neurobiology, coaching, nursing and medicine that moves from “me to we”— I was simply not applying it.  I love working with patients, and my direct patient care work is consistently fun, as I use coaching to partner with my patients to find well-being.

6. Share the tool and info on burnout. In my research, I found that there are 3 kinds of burnout, and I have experienced all 3 during various times in my career.  Like frenetic workaholics, my excessive involvement and over-commitment has at times lead to exhaustion and reactivity. I have distanced to protect myself and became cynical and indifferent, which produced frustration and stress (under-challenged). I felt ineffective and used passive coping strategies, neglected responsibilities and emotionally vented (worn-out).

7. How do clinicians ask questions that help both themselves and their patients? How do we work together to turn burnout into energy that creates well-being? 


Alegría, M., Polo, A., Gao, S., Santana, L., Rothstein, D., Jimenez, A., Hunter, M.L., Mendieta, F., Oddo, V., Normand, S.L. (2008). Evaluation of a patient activation and empowerment intervention in mental health care. Med Care, 46(3), 247-56.

Cortes, D.E., Mulvaney-Day, N., Fortuna, L., Reinfeld, S., Alegría, M. (2009). Patient—provider communication: understanding the role of patient activation for Latinos in mental health treatment. Health Education & Behavior, 36(1), 138-54.

Deen, D., Lu, W.H., Rothstein, D., Santana, L., Gold, M.R.(2011). Asking questions: the effect of a brief intervention in community health centers on patient activation. Patient Education and Counseling, 84(2), 257-60.

Hackman, J. R., & O’Connor, M. (2005). What makes for a great analytic team? Individual vs. team approaches to intelligence analysis. Washington, DC: Intelligence Science Board, Office of the Director of Central Intelligence.

Lu, W.H., Deen, D., Rothstein, D., Santana, L., Gold, M.R. (2011). Activating community health center patients in developing question- formulation skills: a qualitative study. Health Education & Behavior,38(6), 637-45.

Deen, D., Lu, W.H., Weintraub, M.R., Maranda, M.J., Elshafey, S., Gold, M.R. (2012).

The impact of different modalities for activating patients in a community health setting. Patient Education and Counseling, 89(1), 178-83.

Montero-Marín, J., García-Campayo, J., Fajó-Pascual, M., Carrasco, J. M., Gascón, S., Gili, M., & Mayoral-Cleries, F. (2011). Sociodemographic and occupational risk factors associated with the development of different burnout types: The cross-sectional University of Zaragoza study. B

QFT (Question Formulation Technique).

Rothstein, D., & Santana, L. (2011). Make just one change: Teach students to ask their own questions. Cambridge, MA



Additional Tools to assess for burnout:

“Overall, based on your definition of burnout, how would you rate your level of burnout?” 

1 = “I enjoy my work. I have no symptoms of burnout;” 

2 =“Occasionally I am under stress, and I don’t always have as much energy as I once did, but I don’t feel burned out;” 

3 = “I am definitely burning out and have one or more symptoms of burnout, such as physical and emotional exhaustion;” 

4 = “The symptoms of burnout that I’m experiencing won’t go away. I think about frustration at work a lot;”  

5 = “I feel completely burned out and often wonder if I can go on. I am at the point where I may need some changes or may need to seek some sort of help.” 

This item often is dichotomized as ≤2 (no symptoms of burnout) vs. ≥3 (1 or more symptoms).


I feel burned out from my work:  Never, A few times a year or less, Once a month or less, A few times a month, Once a week, A few times a week, Every day

Enable Well-Being

As clinicians, we have an opportunity to coach our patients during their most significant and vulnerable moments. Our job in healthcare and medicine is to enable well-being; and well-being is the reason one wishes to be alive (Gawande, 2014).  It is important that people be able to look at their lives in order to ask the big questions and determine how they want to live.

Clinicians can ask: What is your understanding of the situation and it's potential outcomes? What are your fears and what are your hopes?  What are the trade offs you are willing/not willing to make? What is the best course of action that best serves this understanding?

“What man actually needs is not a tensionless state but rather the striving and struggling for some goal worthy of him. What he needs is not the discharge of tension at any cost, but the call of a potential meaning waiting to be fulfilled by him.” (Victor Frankl)

Oliver Sacks noted that it is not only medicine that is needed in one’s declining years, but a life with meaning, a life as rich and full as possible.  After he  learned that he had terminal cancer, he reported “It is up to me now to choose how to live out the months that remain to me. I have to live in the richest, deepest, most productive way I can.”

"If we wish to know about a man, we ask 'what is his story -- his real, inmost story?' -- for each of us is a biography, a story” (Sacks,1985)  By helping patients write their own stories, we can help optimize their self-perceptions and identify obstacles; in so doing we will enable well-being of both our patients and ourselves.


Gawande, Atul (2014) Being Mortal: Medicine and What Matters in the End

Gawande, Atul (2008) Better: A Surgeon's Notes on Performance. Henry Holt and Co..

Frankl, Viktor E. (1963) Man’s Search for Meaning, Washington Square Press, Simon and Schuster, New York, 1963.

Sacks, Oliver (1985) ”The Man Who Mistook His Wife for a Hat.”

The How, What, Why, and Wherefore of Communication, When the Stakes are High

As evidence based clinicians, we BOTH clarify best practice and preparedness recommendations by transmitting knowledge and information to one another, AND we relate to one another as human beings around the world in the context of relationships, families, organizations, and nations.

We share information such as that found at:

Each individual nurse when faced with a potential for harm, must assess risk. In this time of Ebola, it is absolutely imperative to get things right.  The ANA, AMA and AHA are collaborating for a solution-oriented, collaborative approach to safely provide high-quality, appropriate, patient care.

"While it is effectively impossible to create a risk free environment for nursing practice, the need to recognize, evaluate and efficiently minimize risk while recognizing the responsibility of our profession is an essential component of professional nursing practice. The nurse needs to base his or her assessment of risk on objective, current, and scientifically sound information. Identified risks should be communicated through the appropriate institutional channels so adequate safeguards can be initiated. It is incumbent upon the particular health care institution to provide adequate safeguards such as risk-reducing equipment, enforce protective procedures that minimize risk, educate staff concerning risks, and engage in research to identify actual and potential risks which impact nursing care. The ANA’s Bill of Rights for Registered Nurses states, nurses have the right to a work environment that is safe for themselves and their patients”

 The how, what, why, and wherefore of communication can either harm us or edify us.  As nurses, we check, challenge, test, seek the truth, adjust our ideas, thought processes, clarify our intentions, consciously observe our feelings, and face our opportunities for growth with honesty and courage.  From Florence Nightingale's perspective, nursing is the finest of the fine arts and the work of a nurse is that of a painter sculptor, disciplines requiring exclusive devotion and hard preparation and which incorporate a strong human aspect.  What we say, how we say it, and what we mean by it are extremely important, and can be life-changing. 

 Rosemarie Rizzo Parse’s human becoming theory specifies humans as indivisible, unpredictable, ever-changing beings who are free to choose meaning in situations and who co-create human universe with others, ideas, objects, and situations illimitably.  Health, from the human becoming perspective is a way of living value priorities. The nurse values the client as the co-creator of his/her own health. As nurses we are both becoming purposeful in our efforts to understand guidelines and ask important questions to optimize the care of the patient, caregiver and the community; and we are "purposeful becoming," as we advocate both for our local and global communities.


“Sometimes you have to step outside of the person you've been, and remember the person you were meant to be, the person you wanted to be, the person you are.” (HG Wells)


Deep Listening to find the Joy in "Failure"

Today I became a certified coach, and I am setting out on my challenge at purposefully becoming with my clients.

I coach nurse leaders to create joy in their work and their lives, so that this energy spreads to their patients and coworkers (including their bosses), innovating healthcare.

Fortunately for me, it turns out the sand does not have spell check. Just as I was uploading photos a couple of months ago, I realized my “error” and also recognized that I had to slow down and work on me for a while, so that I could coach myself, in order to be here, now.

I have researched nursing theoretical frameworks, burnout, compassion fatigue, moral distress, motivational interviewing, and work-life fit and my quest is to bring happiness into healthcare.  I am learning to fully engage both in every moment at work and outside of my job, in the world.

My labyrinth logo reflects both our inner and outer journeys, and it looks like a cochlea and a shell for deep listening.  Ironically, most of my professional photos show me helping others listen to their heart, and I now intend to do this more figuratively with intuition and the coaching process.

Coaching skills dovetail perfectly with nursing theoretical frameworks, as life changing skills well suited to nurse leaders.  There are multitudes of randomized control trials supporting motivational interviewing as a tool to improve patient care.  On a larger scale, coaching can improve care of both clinicians and clients.

I love “making a living” as a nurse practitioner and an instructor; however, I am ready to "make a life" by bringing coaching to my profession.

I recognize that I will ever be purposefully becoming and I am thrilled that I will be on the same journey as my clients.


"Success is not final, failure is not fatal: it is the courage to continue that counts."

"Courage is what it takes to stand up and speak; courage is also what it takes to sit down and listen."

"We make a living by what we get, but we make a life by what we give."

(Winston Churchill)

Over the last 6 months, how often have you experienced moral distress in your professional role?

Moral distress is the psychological disequilibrium associated with knowing the ethical/appropriate action to take but being unable to take the action (Jameton, 1984).  It is expected that all healthcare providers working in complex and constrained bureaucratic healthcare systems experience moral distress.

Moral courage is the willingness to take a difficult stance on a controversial issue (Corley, 2002).   Moral residue is that which each of us carries with us from those times in our lives when in the face of moral distress we have seriously compromised ourselves or allowed ourselves to be compromised (Webster and Baylis, 2000).


Suffering for and with our patients is an integral dimension of caring.  Clinicians commit to giving priority to serving others and subordination of self interest.

Our suffering is unjustified when it reaches a magnitude where the professional’s sense of identity and integrity is fractured and the well being of the person is threatened.

When arousal in response to another’s suffering is not regulated, it can give rise to personal distress (Eisenberg, et al., 1994), thereby undermining the possibility for expressing compassion.  This can lead to a stress response and self-focused behaviors such as avoidance, abandonment, numbing aimed at relieving the distress.

The differing perspectives of nurses and physicians can lead to feelings of moral distress (Hamric, 2010). The physician’s focus is often on the “survival of the few”, while nurses focus on the “suffering of the many”. These value systems can lead to tension between the nurse and the physician as members of the healthcare team.

For clinicians of all levels of experience, inadequate coping with such stresses may lead to job dissatisfaction, burnout, isolation, and maladaptive behaviors.  Personal reflection groups like Doctoring to Heal can be adapted for use in a variety of clinical settings.

Managing Moral Distress with G.R.A.C.E© and the 4 “A’s”

G.R.A.C.E© (Joan Halifax, 2012)

Gathering Attention

Recalling intention

Attuning to self and other

Considering what would really serve

Ethically enacting, ending

The Art of Pause

Anchor yourself in your breath, Pause, Be transparent, Monitor your mindset, Explore personal responses, Ask questions, Get clarification, Be open to new possibilities, Let go of outcome, Become a witness rather than an actor.


Bring into your awareness the memory of a patient that you were proud of your service and notice the sensations in your body as you recall this event

4A’s to resolve moral distress:

ASK: You may be unaware of the exact nature ofthe problem but are feeling distress. Ask: “Am I feeling distressed or showing signs of suffering? Is the source of my distress work related? Am I observing symptoms of distress within my team? Goal: You become aware that moral distress is present.

 AFFIRM: Affirm your distress and your commitment to take care of yourself.  Validate feelings and perceptions with others.  Affirm professional obligation to act. Goal: You make a commitment to address moral distress.

ASSESS: Identify sources of your distress (Personal, Environment). Determine the severity of your distress. Contemplate your readiness to act. (You recognize there is an issue but may be ambivalent about taking action to change it. You analyze risks and benefits.)  Goal: You are ready to make an action plan.

Prepare to Act: Prepare personally and professionally to take action.  Take Action. Implement strategies to initiate the changes you desire. Maintain Desired Change. Anticipate and manage setbacks.  Continue to implement the 4A’s to resolve moral distress. Goal: You preserve your integrity and authenticity.


Doctoring to Heal:

My body aches,

My thoughts scatter,

My back hurts,

My stomach aches.

When I'm asked how my mother is

I don't know.

I leave patients when they clearly need to talk.

I keep looking in the fridge.

I feel jittery.

I don't cry when it's sad.

I'm feeling all gummed-up.

I get angry with my cat.

I feel like I'm rattling around on a day off.

I don't know what to do.

I'm exhausted. I feel I can do nothing to right the balance.

I have let go of any semblance of a spiritual life.

I'm worried/anxious about what has been and what's next

Unable to be where I am.

I forget things

Catherine McLean



How might we create a healthy environment where nurses and other clinicians make their optimal contributions to patients and families?



It is one of the most beautiful compensations of this life that no man can sincerely try to help another without helping himself  (Ralph Waldo Emerson)