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