In this episode of Lead Well MD, host Ashley Wendel talks with Dr. Sergio Zanotti, Chief Medical Officer for Critical Care at Sound Physicians and host of the podcast Critical Matters, about what it takes to build what he calls a “Fearless ICU.”
Drawing on decades in critical care leadership, Dr. Zanotti shares why psychological safety is the single most important factor in high-performing ICU teams - and why it’s not about being “soft,” but about creating an environment where people can speak up, learn from mistakes, and still be held accountable to the highest standards.
The conversation explores how psychological safety impacts patient outcomes, team performance, and clinician well-being; the quiet cues that signal whether a team feels safe; and practical leadership actions that foster trust, inclusion, and learning in high-stakes environments.
From COVID-era lessons to everyday ICU rounds, Dr. Zanotti offers both strategic insights and tactical tips - like inviting the quietest voice in the room to contribute - that any clinical leader can apply immediately.
Whether you lead an ICU, a clinic, or a cross-functional team, this episode will challenge how you think about authority, vulnerability, and the real cost of silence in healthcare.
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Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Ashley (00:08):
Hi, everyone.
I'm Ashley Wendel, and this isLead Well MD, a podcast that
explores how leaders cantransform healthcare through
emotionally intelligent,effective clinician leadership.
Today's episode is one thatI've been especially looking
forward to.
I'm joined by Dr.
(00:28):
Sergio Zanotti.
He is a nationally respectedleader in critical care
medicine.
He's the Chief Medical Officerfor Critical Care at Sound
Physicians, and he's the host ofthe podcast Critical Matters.
I brought him on the show todaybecause few people I know
understand the topic ofpsychological safety in clinical
teams as deeply or aspersonally as he does.
And in this conversation, weexplore what it takes to build
(00:51):
what he calls a fearless ICU.
We talk about why psychologicalsafety is essential for patient
care and team performance, andhow leaders can shift from
authority to inclusivity withoutsacrificing accountability.
So let's dive in.
So I am so happy to have Dr.
Sergio Zanotti with me today.
(01:11):
Hi, Sergio.
Sergio (01:13):
Hi, Ashley.
Thanks for having me.
Ashley (01:14):
You bet.
So I wanted to share a littlebit about your background.
That's okay.
Sergio (01:19):
Absolutely.
Ashley (01:20):
All right.
So Dr.
Zanotti specializes in criticalcare medicine and is the chief
medical officer for criticalcare at Sound Physicians.
He's also the director ofcritical care medicine at
Memorial Hermann, Memorial CityMedical Center in Houston,
Texas.
And prior to joining Sound, Dr.
Zanotti was the programdirector for the Critical Care
(01:40):
Medicine Fellowship andassociate professor of medicine
at Cooper Medical School ofRowan University.
You also have your own verypopular podcast, right, called
Critical Matters, which covers awide range of topics related to
the practice of critical caremedicine.
Sergio is also a member of theAlpha Omega Alpha Honor Medical
(02:01):
Society and has receivedmultiple awards for excellence
in medical education.
He was recognized withpresidential citations for his
contributions to the Society ofCritical Care Medicine in 2008,
2014, and 2017.
So amazing.
And I could go on about yourwriting and your lecturing and
your research, but I think I'mgoing to have to leave it there.
(02:23):
Sergio, thank you so much forcoming in and being here with me
today.
Sergio (02:27):
Well, thank you for having me and for the kind
introduction.
Ashley (02:29):
And so in full transparency, you and I have
been co-facilitating aleadership development program
together for sounds, what, 300plus medical directors
nationally for the last coupleof years.
And so we've gotten to knoweach other pretty well.
And I brought you on reallybecause I know that you
understand deeply the importanceof the topic that we're going
(02:50):
to be talking about, which ispsychological safety within
teams and within organizations.
So I can't wait to dive intothat with you today.
Sergio (02:58):
Let's do it.
Ashley (02:59):
All right.
But before we do, I have aquestion.
I want to start with you and Iwant to start with your story a
little bit.
You are known for being a greatleader at Sound.
I have seen it.
I've seen people gravitatetowards you.
You do this really well.
Can you share about yourleadership journey through
critical care and how it shapedyour philosophy as a leader?
Sergio (03:18):
Absolutely.
And I would start by sayingthat it's an ongoing journey.
and that there's alwayssomething new to learn in being
a better leader.
And that a lot of my journeyhas been kind of dictated by
curiosity, by trying to learnnew things.
And I had the opportunity toserve as a chief fellow when I
(03:42):
was in training.
And I originally thought thatwas a distinction, an honor, and
that I would be scheduling thefellows and helping with the
conferences.
But quickly I realized that thereal hard part of leadership is
dealing with people.
And there were a whole bunch ofsituations that even in that
two-year fellowship arose that Iwould have not anticipated and
(04:06):
that I'm sure some I've handledvery poorly, but I tried to
learn from and some I handled alittle bit better and really
started understanding thatleadership is at the end about
helping people move in a betterdirection.
Mm-hmm.
serving people, and thatmanaging is easy sometimes.
(04:26):
You can lead up, and this iswhat you should do as a good
manager.
But dealing with the people isnot always as easy for many,
many reasons that we all know.
And from there, I went intoacademia, very quickly became
the program director of thefellowship program.
So now I was leading thetraining program.
(04:47):
And very similarly, a lot of myactivities changed were related
to scheduling the fellows, torunning conferences, to helping
people do research.
But the hard part was dealingwith the people.
When you had a difficultpersonality, when you had a
difficult relationship among twoof your fellows, or your fellow
(05:08):
got yelled by the CT surgeon,Then the fellow yelled at the
intern.
And that was really the hardpart.
And as a nerd and intensivist,I like to read.
So I started reading a lotabout topics that were not
medical.
Topics about leadership, aboutpsychology.
(05:29):
And started expanding kind ofmy toolkit of things that I
could apply at the bedside.
And that led me...
to become trained in Lean SixSigma, became a black belt.
And it totally changed the wayI was thinking about medicine at
that time.
And then I landed a job withwhat was then the intensivist
(05:50):
group, which quickly became partof Sound Physicians.
And for the last decade, I'vebeen serving as the chief
medical officer of a veryrapidly growing critical care
team.
And once again, it's all aboutthe people and how can you serve
them and how can you help themgrow And that has just been, I
would say, an endless source oflearning for me.
Ashley (06:12):
Yeah, yeah.
I think that one thing I loveand that I'm hearing is a lot of
curiosity.
You carry a lot of curiosity,more than many people I know, to
just keep that learningprocess, keep open to that, keep
reading.
Let me ask you, I want to segueinto this concept of
psychological safety.
And one of the phrases that Ilove that I've heard you use in
(06:33):
our work together is thisconcept of a fearless ICU.
And I think it's a powerfulterm.
If you could describe what youthink that means in just three
words, what would they be andwhy would they be that?
Sergio (06:46):
Well, that's a great question and a hard one.
Yeah.
But if I had to choose threewords, I would say curious,
safe, And accountable.
Curious because I reallybelieve that a fearless ICU is
all about learning.
Learning how to do thingsbetter, but also learning from
(07:07):
our mistakes.
It is impossible to delivercomplex care to critically ill
patients on a daily basis andnot make mistakes.
Ashley (07:17):
Right.
Sergio (07:18):
Does not happen.
Yeah.
So in a fearless ICU, we...
don't want to make mistakes,but when they happen, we embrace
them as a learning opportunityand we can talk about it.
So that leads me to the secondword, which is safe.
I feel safe to not only takerisks as a leader or as a nurse
(07:38):
or as a physical therapist andgiving my opinion, but I also
feel safe in bringing upproblems to the team and to not
be criticized, ostracized, ordemeaned but to be thanked for
bringing up a problem that wecan all work on together to move
in the right direction.
So that's the safety part,which ultimately also plays into
(08:02):
another safety area, which ispatient safety.
If teams can't talk aboutmistakes, it's very difficult to
provide safe care.
And finally, I saidaccountability.
And this is important becausewhen clinicians, especially in
the ICU, which is a high stakes,high adrenaline environment
(08:23):
here, psychological safety, theyimmediately go to like a, oh,
it's a kumbaya thing and like asoft thing.
And it's not about that.
We still want to be accountableto each other.
And what we're looking for isthe highest performance.
But it's come to therealization that without us
having that learning experience,growth mentality without making
(08:46):
it safe and inclusive foreverybody, we cannot perform at
the highest level, period.
We just can't.
So accountability is important.
The goal is to perform at thehighest level.
These are very sick patientsand things we decide can really
make the difference betweensurviving and not surviving.
(09:07):
Sometimes there is no chancefor surviving, but we still want
to perform at a high level andmaking sure that we can take the
family through that process inthe most compassionate way.
So I think that going back tothe three words, it would be
curious, safe, and accountable.
Ashley (09:24):
Right, right.
I love that you added theaccountability because you're
absolutely right.
In leaders that I've workedwith, one of the biggest
misconceptions I hear is, aboutthis concept of psychological
safety is that they think it'ssomehow going to be coddling
people.
It's going to be too easy onpeople.
You know what, we're going tojust, you know, be soft and give
(09:44):
them everything they want.
They don't realize that that'sexactly the opposite of what
we're talking about.
We're talking about maintainingthose high performance
standards, but making anenvironment where that can
actually function.
Yeah.
Yeah.
Why do you think it's socritical in clinical
environments that this exists?
Sergio (10:03):
Critical care is probably a magnified example of
healthcare.
But if you took healthcare as awhole, the reality is that it's
a complex environment with highstakes.
And as a complex environment,we know parts of what we need to
do, but we don't always knoweverything we need to do.
(10:23):
It's not like if you're bakingbanana bread, there's 10 steps,
exact proportions.
And if you do that, you'reokay.
In critical care, you might dothe first 10 steps right, and
the outcome might still be anegative one.
So it's a complex environment.
As such, you're constantlytrying to learn, but you also
have a lot of moving parts.
(10:43):
And if those parts don't feelsafe to interact, to show up in
their best version, to givetheir opinion of what might
help, or to say, I don't know.
Could you show me?
I'm not sure what to do.
Can you help me?
I just made a mistake.
We need to fix this.
(11:04):
It's impossible to deliverhigh-level care consistent.
And it's very interesting thatin medicine, we are taught that
failure is bad.
Now, there are different typesof failure.
Some of them should absolutelybe avoided 100% of the time.
Like if you go to surgery for aright leg amputation and they
(11:25):
amputate the left leg, well,that's a Never event.
That's a problem, right?
However, there are situationsin where we might fail in saving
a patient, but everything wasdone right.
So how do we learn from that?
And the ability to learn fromfailure is embedded or based on
psychological safety.
Can we talk about what we didwrong or what we could do better
(11:49):
in a safe way where everybodycan learn?
And that is the most importantfactor to provide safe care, but
also ensuring to keep evolving.
We have situations like COVIDwhere we have no idea what to
do.
Well, if you're not in apsychological safe ICU, how are
you going to learn as quickly asyou need to provide that care
(12:09):
to those patients?
And running several ICUsthrough our practice, I saw
that.
I saw some ICUs did better thanothers.
with the same amount ofinformation, the same level of
ignorance, right?
But some ICUs were safer from apsychological standpoint, and
they worked as a team to figurethings out.
(12:29):
And others were paralyzed bythe fear of failure, by the fear
of communicating.
And ultimately, the patientsare the ones who have to pay
that price.
Ashley (12:39):
You had Dr.
Amy Edmondson on your podcasttwice.
And Amy Edmondson is, ofcourse, the person who came up
with the concept ofpsychological safety through her
research and her work over theyears.
And I'm curious, because yourpodcast is really focused on
clinical care medicine, and yourlisteners are clinical care
physicians for the most part,what drove you to bring her on?
(13:00):
And why did you think that herwork was so important for your
listeners to understand?
Sergio (13:05):
That's a great question.
And I would say that The reasonwhy I brought her on is the
reason why she probably acceptedto do it.
Amy Edmondson, as youmentioned, is a professor at the
Harvard Business School.
She has done amazing researchin the area of work
(13:26):
environments, complex workenvironments and performance and
coined the term psychologicalsafety.
She has studied ICU teamsthroughout her career.
in terms of identifying whatare the factors that make one
team perform at a high levelversus a team not perform so
well.
And she's identified that themost important factor is
(13:46):
psychological safety.
Yet as relevant as her work andher findings are for the
practice of critical caremedicine, it is not discussed in
clinical arenas.
Now people are talking aboutthis concept, but when I was a
fellow, I didn't even know thisword existed.
Ashley (14:05):
Yeah.
Sergio (14:05):
When I was a young attending, starting a
fellowship, it wasn't even onthe radar of things that we
should teach the fellows.
Yet, it's probably the singlemost important thing in
performing at a high level dayin and day out.
We train critical carephysicians to be the leaders in
the ICU, but we weren't trainingthem or teaching them about the
(14:28):
most important thing theyshould build in their ICU.
We were talking about all thesediseases and mechanical
ventilators and drugs to raisethe blood pressure and diseases
like ARDS and septic shock,which is all important.
But without psychologicalsafety, it's impossible for a
team to perform at their highestpotential.
(14:50):
And that is what we all wantwhen we show up to work.
So that was the reason why Ithought it was important for her
to come and share her messageand her insights and what she
learned through years ofresearch.
And I believe that that's whyshe also thought it was
important to talk to a veryclinical audience because she
recognizes that it's almost likeparallel worlds.
Ashley (15:09):
Yeah.
Sergio (15:10):
And we need to connect a little bit more.
Ashley (15:12):
Yeah.
Yeah.
Did you get any feedback fromyour peers on those
conversations?
Sergio (15:18):
I did.
And when you do a podcast orwhen you give a lecture or write
something, you want it to havethe maximal quality.
But the reality is that as longas a couple of people take it
to heart and they do somethingto change what they're doing,
it's a win.
And I actually know some ICUdirectors and fellowship
(15:42):
directors who really embracedthe concept and was like an aha
moment.
We should be teaching this toour team.
We should be talking aboutthis.
One of my friends who I hadtrained and now is the head of
critical care at a largeuniversity program bought Amy
Edmondson's book for the wholeteam and they started reading
it.
So I do believe that itresonates with a lot of people.
Ashley (16:05):
Yeah.
Sergio (16:06):
And what I found also, Ashley, is that I have done a
lot of talks around the world,actually, about the fearless
ICU.
Ashley (16:13):
Yeah.
Sergio (16:14):
And I've talked about this in the United States and
different settings.
I've talked about it in theMiddle East, South America, in
Mexico, in Europe.
And what I find is that whenpeople hear the talk and the
concepts, they immediatelyrecognize something they live
every day.
(16:34):
Yeah.
But all of a sudden they have alanguage that Amy Edmondson has
created to articulate it, toexplain it.
And it's like, Yes.
This makes perfect sense.
Right.
Right.
Thank you for sharing this.
So I definitely think that itresonates with clinicians
because everybody who's acritical care clinician has seen
(16:56):
what psychological unsafe teamslook like.
Yeah.
Yeah.
Some have seen what good lookslike, but everybody has seen
what bad looks like.
And they can say, yes, I seethat.
It resonates.
Now I know there are things Ican do to change it.
Ashley (17:13):
Yeah, yeah.
Sometimes it's so much easierjust to be able to identify the
things you don't want before youcan really shape what you do
want.
Well, let's talk about mindsetbecause a lot of this is about
that, right?
That shift of mindset becausewe know that most clinicians are
trained to lead with authority,with certainty, with expertise,
(17:34):
even perfection if we go downthat road.
But this takes a little bit ofa shift.
So how do you help yourclinical leaders shift their
mindset and lean a little bitmore into some of the behaviors
that psychological safetyrequires, like being a little
more vulnerable, being a littlemore open?
How do you do that?
Sergio (17:53):
Yeah.
Well, the best way to shiftpeople's mindset is to ask
questions and asking questionsthat lead them to the answer you
want.
I think that's a great way tostart.
But also a lot of times it'sjust showing them or
exemplifying the behavior,obviously, but also pointing out
(18:14):
to our leaders or to ourcolleagues examples of why
psychologically unsafe behaviorsare detrimental to our patients
and to our team.
And it's a little bit of acombination of asking questions,
role modeling, and giving thepeople feedback of, the damage
(18:35):
that bad behavior does in thatrespect.
Ashley (18:38):
Right, right.
Yeah, that makes sense.
Sergio (18:40):
And talking about it, obviously.
We talked about the Furious ICUin our leadership meetings.
We talk about it in clinicalsettings and fellowships now.
So also, the first step is toidentifying we have a problem
and talking about it and tryingto provide some solutions.
And again, some people embraceit, but not everybody.
That's okay, as long as we'removing the needle.
Ashley (19:02):
That's right.
That's right.
Critical mass.
All right.
Is there a moment that you canshare that you've actually seen
a team have a breakthrough inpsychological safety and what
made that possible in thatexample?
Sergio (19:17):
So as a breakthrough, I would say that studies have
shown, and a lot of thesestudies, again, come from Amy
Edmondson's team, that thequality in a leader that most
likely correlates topsychological safety is being
inclusive.
Ashley (19:32):
Okay, yeah.
Sergio (19:32):
So breakthroughs I've seen in clinical care when
they're rounding and the newnurse doesn't really speak up
during rounds.
And the intensivist who'sleading the rounds might say
something like, Ashley, I knowyou're new to the team.
You've been very quiet duringthis patient's presentation, but
(19:56):
you are helping care for thispatient.
I really want to hear youropinion.
It's important for us.
What do you think we should bedoing?
Or is there something that weshould know?
And it gives them permission tocontribute.
And I think, especially inmedicine, which is very
hierarchical sometimes, that'shard for new people.
(20:16):
A similar breakthrough might bein a team meeting among
physicians.
When there's one physicianwho's very quiet about a new
change that you're trying toimplement to the ICU.
And again, you might say,Sergio, You've been very quiet.
I can't read if you're inagreement or disagreement, but
either way, your opinionmatters.
(20:36):
Could you share what you'rethinking with us?
Bring them in, invite them totalk with you.
That is the best way I believeto break through.
The other breakthrough thatI've seen in different settings
is how a leader handles badnews, right?
Do we shoot the messenger?
Ashley (20:57):
Right.
Exactly.
Sergio (20:59):
And then obviously people are going to say, well,
I'm not talking next time.
Or do we acknowledge theproblem and thank the messenger
for bringing it up to the team?
Ashley (21:08):
Right.
Sergio (21:09):
When they question something you are doing as a
leader, obviously your initialreaction is to be defensive, but
you might say, you know what?
I hear your point.
Thank you for bringing this up.
Let's talk about it.
So that is a great way ofcreating a small breakthrough
with psychological safety.
Ashley (21:28):
Isn't that what Amy Edmondson calls responding
productively, right?
When somebody does take a riskand come to you with something,
the way that you respondmatters.
Absolutely.
You know, the other thing thatpops into my mind is we've
talked in the past aboutpeople's experience of
psychological safety isdifferent.
And there are different factorsthat attribute to that.
(21:49):
And just being aware of thatfact, whether it be hierarchy,
whether it be are theynon-native English speakers,
gender, all kinds of things thatcan get in the way where we
might assume their psychologicalsafety, their experience of it
might be different.
Sergio (22:05):
Absolutely.
And again, there are studies inmedicine.
about this and on averagephysicians are going to feel
safer in the ICU than nurses whoon average feel safer than the
respiratory therapists and itmight have to do with perceived
roles with number of people withyears of experience it was a
(22:25):
lot of of issues but you'reright and we have to acknowledge
that as a executive physicianwho's a middle-aged white male I
have a lot of privilege and Ifeel very safe, but I don't have
to assume that everybody on myteam feels the same thing I
(22:45):
feel.
Ashley (22:45):
Right.
Sergio (22:46):
Right.
And being able to recognizethat is important.
And the way you slowly movethat needle is by making sure
that everybody is included andfeel they belong to the
Ashley (22:58):
team.
Right.
Exactly.
Well, let me ask you this.
We were talking a minute agoabout the data that supports
this.
And I think that's a reallyimportant point because too many
people might have themisconception that this is a
soft science.
But this is not just a softscience, right?
There's more and more studiesthat have been done in
healthcare that demonstrate theimpacts to really measurable
(23:20):
outcomes, right?
Safety, quality, teamperformance, morale, retention,
all those factors.
What measurable impacts haveyou seen in your experience on
those kinds of outcomes whenpsychological safety is
prioritized in a team?
Sergio (23:37):
Well, I think that one of the things that is very
evident is the number of safetyreports that a team will submit.
If you have two ICUs and onereports on average, let's say
six to seven patient safetyevents every month, and the
(24:00):
other ICU reports zero, yourfirst thought is that I want to
be in the second ICU becauseit's safer.
My thought, based on the data,would be I want to be in the
first ICU because in both ICUsthere's problems, but only the
first ICU talks about them.
Ashley (24:17):
That's right.
Sergio (24:18):
And I always say with patient safety, the ultimate
measure of clinicians feelingsafe is when they self-report
patient safety events, which isvery hard, right?
When they self-report, can wereview this case I was involved
with?
I think I may have made amistake.
That is the ultimatemeasurement of psychological
(24:39):
safety, and it's hard toachieve.
But also, there are very goodstudies outside of medicine.
Google did a massive studywhere they looked at what were
the determinants ofhigh-performing teams, and this
is performance-measured bydollar signs, right?
Which teams deliver the highestreturn, the highest product,
(25:02):
and the single most importantfactor by far was psychological
safety.
Does the team members feel safeto ask questions, to interact,
to show up at their bestversion, to take small risk?
So it's there, you can see itin different outcomes for sure.
Ashley (25:20):
Well, let's make it really clear.
If you're on that team in theICU that maybe doesn't have as
great a psychological safety asthe other one, what do you think
signals to people that it's notsafe to speak up?
What kinds of things would behappening?
Sergio (25:36):
Part of it might be learned behavior from previous
jobs.
A lot of times, new members andteams in health care constantly
change, not only over time, buton a daily basis, this concept
of teaming, right?
People show up as a differentteam every day in some respects.
So they might have learnedbehaviors from other teams,
(25:57):
which unfortunately is veryprevalent in healthcare that we
have psychological unsafe teams.
And maybe they saw somebodyelse get into trouble for
bringing up a problem, so theydon't want to bring it up.
Or they presence that somebodyasked a question and got reamed
or got demeaned or gotridiculized for not knowing
(26:18):
something.
Or there was a difficultpatient interaction and the way
the people involved reacted wasvery negative.
So these are all things thatwould push me as an individual
to not take that risk.
I don't want to be seen asincompetent.
So I'm not going to ask if Idon't know.
(26:39):
I don't want to be seen asdisruptive.
So I'm not going to say, well,maybe we should do this
different.
I don't want to be seen asnegative.
So I'm not going to say we havea problem.
And these are just normal humanbehaviors that we all have.
But if we are in a businessthat's here just taking care of
critically ill patients, you gotto put what's best for the
(27:00):
patient first.
Ashley (27:01):
Yeah.
And what's the cost of thatsilence in your mind?
What is the cost?
Sergio (27:05):
It's death.
Death for the patient.
Death for other people.
When you mentioned the cost ofsilence, there's a lot of case
studies about NASA and the SpaceShuttle Challenger, I think it
was, or Columbia.
I don't remember which one.
That obviously exploded on theway back and one on the way up
(27:26):
and one on the way back andkilled seven astronauts.
Ashley (27:30):
Yeah.
Sergio (27:31):
When they actually investigated what had happened,
Ashley (27:34):
What
Sergio (27:34):
they found was that there was a pervasive, unsafe
psychological environment inNASA and that people who knew
that there was a problem did notfeel empowered or did not feel
capable of speaking up to theright person.
So it leads to death.
We see it in medicine.
There are famous cases of wrongside surgery, giving somebody a
(27:55):
medication that they'reallergic to.
Now, there's a lot ofsafeguards in place for that now
with checklists and all that,but every time they reviewed one
of these seminal cases, therewere people involved in the care
that thought something waswrong, but didn't feel safe to
speak up.
Right.
So the consequence is death.
Ashley (28:15):
Yeah.
Yeah.
Truly.
Yeah.
Sergio (28:17):
Truly death.
Yeah.
Ashley (28:19):
Wow.
Wow.
Well, what is your way to lookat a team if you're going out
and gauge where they're at intheir level of psychological
safety?
What kinds of or signals orbehaviors helps you see where
they are.
Yeah.
Sergio (28:36):
So one of the things that you can observe very
quickly is how people contributeto the conversation.
If there are some team membersthat are always silent, it
immediately makes you wonder,okay, do these people feel safe
to talk?
Because at the end of the day,everybody knows something that
(28:59):
you don't know.
Everybody knows something thatsomebody else doesn't know.
So when you're trying to workas a team, you have to have, you
always have something tocontribute.
Ashley (29:08):
Right.
Sergio (29:08):
No matter what the role is.
So when you see silence on arepeated basis or when you see a
team get bad news and there'sno response.
Right.
Okay.
You wonder, is it really nobodyhas any questions?
We just changed the way we runour call schedule and there's no
questions.
(29:28):
Yeah.
Right.
No, this is an unsafe team.
And then also, obviously, whenteams have a death or a
difficult clinical situation ora mistake or a problem, how they
react, that can be very tellingin terms of the level of
psychological safety that thereis.
(29:50):
A low level would be somebodybeing berated during a
resuscitation for not doingsomething fast enough.
you got to take care of thepatient, but that's not the time
to berate somebody or howpeople respond to questions.
Like something along the lines,you should know that is not
(30:11):
psychological safe.
Ashley (30:12):
Right.
Sergio (30:13):
Right.
Our job is to make sure thatthey, that they learn it.
Ashley (30:16):
Right.
Sergio (30:16):
And if somebody asks a question, they should be
applauded for asking thequestion.
Ashley (30:20):
Right.
Sergio (30:20):
Because they're wanting to do their job better.
And if they don't know, theyshould ask.
Right.
Ashley (30:25):
Yeah.
Sergio (30:26):
Um, In terms of psychological safety also, if
somebody can point out thatsomebody's about to do something
that might be dangerous in aproductive way, how that person
responds, if they're defensiveversus you're right, thanks for
pointing that out for me, that'sa psychological safe
environment.
(30:46):
And what I would also say thatit's no different in families
and and relationships.
It's true.
You might not get a goodpicture just on a brief
interaction.
Right?
We all know perfect couples whothen totally, right, become
among our friends and you don'tknow the tip of the iceberg that
(31:09):
you see.
So you have to be a little bitmore embedded in the team to
really appreciate how the teamfunctions.
Ashley (31:17):
Right.
Sergio (31:17):
So a lot of my experience insights into where
teams are safe or unsafe mightbe talking in more depth with
members.
But just from observing themsometimes, you don't always
tell.
True.
But like I mentioned, when yousee those telltales, okay, you
say this is probably a team thatis safe.
(31:38):
This is probably a team that isnot as safe as they should
Ashley (31:42):
be.
Yeah, there are clues.
There are clues.
I agree.
For sure.
And I think this is a majorproblem.
And unfortunately, I think toooften the aspect of unsafe teams
are what we're seeing more.
We're trying to turn the tide.
We're trying to get thatlanguage out there, that
awareness.
What do you think are some ofthe biggest cultural or systemic
barriers to this that you seein either the ICU setting or any
(32:05):
clinical setting?
Sergio (32:06):
I'll answer that question through the lens of the
ICU because that's what I knowand what I believe.
I would say that one of the bigbarriers is What we've learned
before.
Ashley (32:16):
Yeah.
Sergio (32:17):
Right.
It's almost like it'sgenerational trauma that keeps
going forward.
Right.
Yeah.
We grew up in a medicine hasalways been about not making
mistakes.
Ashley (32:30):
Right.
Sergio (32:31):
And the idea of the superhero.
Yeah.
Ashley (32:35):
Yeah.
Sergio (32:36):
Superheroes are not usually vulnerable, right?
Ashley (32:38):
Right.
Sergio (32:39):
So if you had a bad outcome in a case and you would
present as a fellow in M&M,instead of trying to learn as a
team, it's almost like theanswer is always, I will do
better next time.
Ashley (32:51):
Right.
Sergio (32:52):
So you're taking the blame.
Right.
So you bring that baggage withyou.
So that's the first bigproblem.
Second barrier is I don'tbelieve that most clinicians
have the framework and languageto talk about this and to move
the needle productively.
These are skills, right?
It's not like leaders are, wetalk about this all the time.
(33:12):
They're not born.
It's not like, okay, this is aninclusive leader from birth.
And this is a leader who justcreates chaos everywhere they go
from birth, right?
No, these are learnedbehaviors.
And to learn them as a skill,you have to have the language,
the framework, and you have totalk about it.
which again, I mean, if youwere to look at critical care
(33:35):
training programs, probably 10years ago, I would say zero
talked about this topic.
Now, I would say it's a smallpercent, but the majority of
trainees get to the ICU withoutany real discussion about these
topics.
The last barrier I would say isthat We always make the analogy
(33:59):
of the ICU team as being asports team, right?
Or we're high-performing,depending, I mean, which sport
you like and which era you grewup.
I trained in Chicago in theMichael Jordan era, so you would
talk about the Bulls as theultimate team, right?
The reality is that we don'thave that in the ICU because
every day I show up to the ICU,it's different people.
(34:19):
Some people I'm more familiarwith, but some people I might be
meeting for the first time.
And you have to create apsychologically safe environment
all the time, every day, right?
Get to connect with people whoyou don't know very well in a
safe manner.
And that's a barrier, but it'ssomething we need to learn
(34:41):
because that's just the realityof healthcare.
Ashley (34:43):
Yeah, yeah.
One thing I thought about whenyou were talking too about how
this is a skill, right?
This is something you candevelop.
I think it is about learning asmuch as it is about unlearning.
old behaviors, old ways ofthinking, old entrenched
anxieties and that baggage thatwe bring into it, then that's
hard sometimes.
But at least acknowledging thatthose things have existed, I
(35:05):
think is really important.
Sergio (35:07):
Absolutely.
Ashley (35:08):
To then be able to take that next step.
Sergio (35:10):
Yep.
We have to outgrow old modelsof leadership, old models of
performance, old models ofteamwork, for sure.
Ashley (35:20):
Yeah, yeah.
Well, you, I think, are reallyin a unique position because
you're a practicing physician,but you're also a chief medical
officer, right?
And that bears a wholedifferent sort of
responsibility.
So as that level of leader,what specific actions do you
feel that leaders within yourcare need to take to create and
(35:42):
sustain a psychologically safeculture in their groups?
Sergio (35:46):
You know, Ashley, from working with me that I like
three, so I'll give you three.
where you are in your journeyor where you are within your
organization, whether you hold atitle or not, these three
behaviors can help promotepsychological safety for a team.
Number one is to frame the workappropriately.
(36:08):
What do I mean by that?
When we were taking care ofCOVID patients, we had to
acknowledge that, yes, thismight be dangerous for us.
Yes, we have no idea.
where this is the right thingor the wrong thing to do for the
patient.
So there are all these limits.
That's being vulnerable.
So acknowledge the work.
But also when you have veryclear deliverables that are
(36:33):
expectations, say that to theteam very clearly.
This is what we expect.
This is what for today.
This is the goal.
This is what I expect from theteam members.
This is how we can make thishappen.
So frame the work.
very, very accurately in termsof what's expected, but also
what's unknown or what might beproblematic.
(36:57):
Number two is respondappropriately, like you said,
and you talked about AmyEdmondson emphasizing this.
What do I mean by that?
If somebody does somethinggood, recognize that in public,
right?
If somebody does somethinggood, that does not conform with
the norms of the team, talk tothat person in private, but
(37:19):
immediately.
If somebody asks a question,answer the question without
demeaning the person.
If somebody brings up aproblem, acknowledge the
problem, thank the person forbringing it up, and then take
care of it.
How we respond to bad applessends a big message.
If we have a team member thatis constantly demeaning others,
(37:44):
being unprofessional, and weallow that to go on and go on
and go on, the team's not goingto feel safe.
And eventually other people aregoing to assume that's allowed
and they might do it as well.
So responding appropriately togood behavior, to bad behavior,
to bad news, to good news issuper important.
And it always sends the signal,right, to others.
(38:07):
And finally, the third is aboutbeing inclusive, which really
means inviting people toparticipate.
Constantly inviting people toparticipate, but also valuing
what they have.
Now, if I'm in charge of makinga decision, I can invite to
give me your opinion.
It doesn't mean that I have todo what you say, but if I
(38:30):
acknowledge your position oryour opinion as a valid one and
we take it into consideration,
Ashley (38:35):
I'm
Sergio (38:36):
including you in the conversation.
And then you will feel that youbelong to the team because
eventually they will follow youropinion, right?
So I think those three things,framing the work appropriately,
responding productively, andinviting people to participate
are three things that we can alldo, right, on a regular basis
(39:00):
to move the needle there.
Ashley (39:02):
Yeah, yeah.
And I think on that last pointabout Listening to people's
points of view, I think a secondpart to that was once you've
taken in their point of view andyou validate it, there's
follow-up.
There's a loop there that Ithink sometimes is whether or
not anything happened from whatthey wanted to say, but just
recognizing and following upwith them so that they
understand that something wasactually done with it, I think
(39:23):
can be also very much a part ofthat.
Sergio (39:26):
Absolutely.
Ashley (39:27):
Yeah, yeah.
I think that's great.
Now let's get tactical.
You've got one leader in frontof you, maybe a newer leader.
or somebody who really wants tostart doing this today, start
doing it well, what's the firstthing that you think they should
do?
Where should they begin?
Sergio (39:45):
Inviting the people who don't talk to share their
opinion.
Ashley (39:50):
Yeah.
Why do you think that one inparticular?
Sergio (39:53):
Because it lowers the decibels of tension and
immediately signals to the team,my opinion is valuable.
And also...
I share this because one of themost common things we do in the
ICU is we do clinical rounds.
So the day usually starts, youget there, you get signed off
when the person was there beforeyou.
(40:15):
At night, let's say, you kindof start seeing patients and
then at a given time, dependingon the ICU, eight, nine, it
already gets together at one ofthe beds and we start talking
about each patient.
So there's a group of peoplethat are talking about the
patient.
And if somebody's not sharingthat you might not have time to
every single time have everybodyone's opinion.
(40:37):
But if you notice that somebodyis very silent, asking them for
an opinion and telling themthat your opinion is important
and valuable, signals to theteam safety.
So that's the first thing Iwould do.
The same example would be in ateam meeting with colleagues.
(40:57):
As you know, and you workedwith us for many years,
collaborated with Sound, we havemultiple practices around the
country.
And usually the team ofclinicians that includes
physicians, APP, CRNAs, and insome instances, nurses might
have a team meeting.
And maybe the director, theprogram director is sharing a
(41:18):
new demand from the hospital,something the hospital wants us
to do, which you immediatelythink is a new brick on their
backpack.
Ashley (41:24):
And
Sergio (41:25):
now they want us to do this, right?
Everybody's rolling their eyes,but nobody says anything.
Or everybody talks and thensomebody's silent.
Ashley (41:33):
Yeah.
Sergio (41:34):
You know that they're not feeling safe to share or
they feel that they share it's awaste of time.
Now, we might not be able tochange what needs to be, what
they've asked from us.
Right.
But people can still talk.
share what they feel and why,and maybe you can show them by
asking them some questions thatmaybe they're looking at through
the wrong lens.
(41:54):
So that's another example.
Invite them to participate.
20 members not talking at all.
Joe, I noticed you're verysilent.
We really value your opinion.
Could you share with us whatyou're thinking?
And it's possible that Joedoesn't say anything that time,
but you make that note and nexttime.
Ashley (42:13):
Yeah.
Sergio (42:14):
You ask them.
And if you're running a meetingwith a small number of people,
you should be checking, right,who's talking and who's not
talking.
Ashley (42:23):
Right.
Sergio (42:23):
There's a fascinating study from the MIT group many
years ago that looked at theperformance of teams.
And these were smaller teams,like three to five people
working on creative tasks.
And what they found is thatEqual speaking time
Ashley (42:39):
was
Sergio (42:40):
one of the most important factors, right?
And it speaks to psychologicalsafety.
Everybody felt safe to givetheir opinion.
So when you have more angles atit, you can find more creative
solutions.
Ashley (42:52):
100%.
And what I was thinking about,and it's so great that you
brought that up, is I think alot of leaders, especially young
leaders, feel the need to talka lot.
Right.
They're driving the meeting.
They've got to be the ones outin front.
And there is power in maybesetting it up, but then stepping
back and letting the otherstalk.
And that's, I think, a perfectexample of
Sergio (43:11):
that.
Absolutely.
Absolutely.
Ashley (43:14):
All right.
Well, I've got a couple morethings for you before I cut you
loose, Sergio.
So I want to think about you.
If you were to look back, lookat yourself 20 years ago.
What's something that you wouldsay to yourself or something
you wish that you would havelearned earlier in your career
that maybe you You couldn't useback then.
Sergio (43:33):
It's funny that that question comes now because you
just mentioned me as a youngleader.
Ashley (43:37):
Okay.
Sergio (43:38):
I would say listen more, talk less.
Yeah.
And about listening, what Iwould say is listen with the
intent of learning.
Ashley (43:50):
Right.
Sergio (43:52):
And I look at some of my first leadership, quote
unquote, leadership meetings.
Ashley (43:57):
Right.
Sergio (43:57):
Which I thought I had.
nailed it then I realized all Idid was talk yeah what a
failure right and I stilleverybody likes to talk and you
know me I like to share ideasand talk but I would say that
talk less listen more yeah isthe most important lesson I
(44:18):
would teach my younger self yeahbecause it makes such a
difference right
Ashley (44:25):
yeah yeah well absolutely I love that All
right, so last thing I want todo with you, if you're down for
it, if you're game, I'm going toask you my quick set of
questions I like to ask peopleat the end.
How do you feel?
Are you good?
We're ready?
Okay.
So the first one is, what's oneword to describe your
leadership style?
Sergio (44:45):
Curious.
Ashley (44:46):
I like that.
What is a leadership value thatyou won't compromise on?
Sergio (44:51):
Kindness.
Ashley (44:53):
Yeah, that makes sense.
What's the most important habityou've built as a leader?
Sergio (44:59):
Ah,
Ashley (45:00):
okay.
Why that?
Sergio (45:04):
Because it's like networks.
There's strong ties and weakties.
And when you read a lot ofdifferent topics, it's almost
like you have a big network ofweak ties that all of a sudden
give you answers or show youpaths.
That if you just read medicine,you would have never found.
Right.
(45:25):
So I think that expanding yourbrain by reading a lot and
different things can really helpyou in your day-to-day work.
Ashley (45:32):
Love it.
Love it.
All right.
So what is one thing that helpsyou reset after a tough day?
Sergio (45:38):
My dogs.
Ashley (45:42):
Nice.
What was it?
but my
Sergio (45:45):
kids are all gone and my granddaughter is in New York
but yeah my family my dog mypets I think especially the dogs
because they're with me rightnow and they're I wish that we
all behave like them they're sonoble right and They always seem
to be living in the moment.
Ashley (46:04):
They do.
Sergio (46:04):
Which I believe is very resetting for me.
Ashley (46:08):
Yeah.
All right.
What is something you used tobelieve about leadership that
you no longer do?
Sergio (46:14):
That you have to be the smartest person in the room to
lead.
Ashley (46:19):
Yeah, for sure.
What is the biggest lesson thatyou've learned from your team?
One
Sergio (46:25):
of the things I've learned from my team that has
been very humbling is that Don'tassume that what you value is
what other people value.
Ashley (46:32):
Yeah, yeah.
Sergio (46:33):
And I think it's true for patients too.
Ashley (46:35):
Agreed.
That's a good one.
What's your favorite questionto ask in a one-on-one?
Sergio (46:41):
About books.
The book that has influencedyou the most or what book have
you read lately?
And that's very, I want tolearn, but also I'm looking for
more things to read.
Love it.
Ashley (46:50):
Love it.
Well, on that topic, what's abook or resource that you think
every physician leader shouldknow about?
I
Sergio (46:56):
have found that Meditations by Marcos Aurelius
is a phenomenal read and I readit over and over again.
Really?
And what it's taught me is thatif the most powerful person on
earth at that time
Ashley (47:12):
was
Sergio (47:14):
so humble and really thought of leadership as a call
to serve others, who am I toargue?
And it's a great example of howto really Lead by trying to
improve yourself, but also byrecognizing that the value in
leadership is not in what youachieve, but in what you achieve
(47:36):
for others.
Ashley (47:37):
Yeah.
All right.
Last one.
One thing every physicianleader should try this week.
Sergio (47:48):
To include, invite somebody to participate in a
meeting or in a clinical roundsor in a patient discussion.
Ashley (47:56):
Love it.
Love it.
Well, Sergio, thank you somuch.
I've so appreciated you beinghere.
I appreciate your thoughts,your wisdom, your candor.
Always appreciate it.
And
Sergio (48:07):
as
Ashley (48:07):
a leader and as a human.
The
Sergio (48:09):
same here.
And I appreciate having theopportunity to talk with your
audience and on your podcast andalso...
Appreciate the opportunity thatwe've had over the last couple
of years to partner together andteaching, but really in
learning together, which isultimately the most important
thing.
Ashley (48:24):
Agreed.
Agreed.
My thought is you are such adelight to work with.
You really are, Sergio.
I appreciate that so much.
I love sharing that teachingspotlight with you and agreed.
I've learned so much from you.
So I hope you come back.
I know we can find other thingsto talk about.
I love your insights and yourthoughts.
So thank you so much.
Sergio (48:41):
Thank you.
Ashley (48:42):
All right.
Take care.
For everyone listening, I hopeyou found this conversation with
Dr.
Zanotti as thought-provoking asI did.
His perspective on curiosityand the quiet signals of
psychological safety in teamsreally underscores how
leadership is less about knowingall the answers and more about
creating the conditions whereothers can speak up and show up
(49:05):
and grow.
So if you're a clinician leaderwondering where to start,
remember Serge's advice.
Invite somebody into theconversation, especially the
quiet ones.
Psychological safety startswith those small, intentional
acts of inclusion.
Thanks, everybody, forlistening.
And if you found value intoday's episode, please consider
sharing it with a colleague orleaving a review.
(49:28):
And if you're not alreadysubscribed, hit that follow
button so you don't miss futureepisodes.
Thanks for being here.
Take care, and I'll see younext time.
Hi, everyone.
I'm Ashley Wendel, and this isLead Well MD, a podcast that
explores how leaders cantransform healthcare through
emotionally intelligent,effective clinician leadership.
Today's episode is one thatI've been especially looking
forward to.
I'm joined by Dr.
(00:28):
Sergio Zanotti.
He is a nationally respectedleader in critical care
medicine.
He's the Chief Medical Officerfor Critical Care at Sound
Physicians, and he's the host ofthe podcast Critical Matters.
I brought him on the show todaybecause few people I know
understand the topic ofpsychological safety in clinical
teams as deeply or aspersonally as he does.
And in this conversation, weexplore what it takes to build
(00:51):
what he calls a fearless ICU.
We talk about why psychologicalsafety is essential for patient
care and team performance, andhow leaders can shift from
authority to inclusivity withoutsacrificing accountability.
So let's dive in.
So I am so happy to have Dr.
Sergio Zanotti with me today.
(01:11):
Hi, Sergio.
Sergio (01:13):
Hi, Ashley.
Thanks for having me.
Ashley (01:14):
You bet.
So I wanted to share a littlebit about your background.
That's okay.
Sergio (01:19):
Absolutely.
Ashley (01:20):
All right.
So Dr.
Zanotti specializes in criticalcare medicine and is the chief
medical officer for criticalcare at Sound Physicians.
He's also the director ofcritical care medicine at
Memorial Hermann, Memorial CityMedical Center in Houston,
Texas.
And prior to joining Sound, Dr.
Zanotti was the programdirector for the Critical Care
(01:40):
Medicine Fellowship andassociate professor of medicine
at Cooper Medical School ofRowan University.
You also have your own verypopular podcast, right, called
Critical Matters, which covers awide range of topics related to
the practice of critical caremedicine.
Sergio is also a member of theAlpha Omega Alpha Honor Medical
(02:01):
Society and has receivedmultiple awards for excellence
in medical education.
He was recognized withpresidential citations for his
contributions to the Society ofCritical Care Medicine in 2008,
2014, and 2017.
So amazing.
And I could go on about yourwriting and your lecturing and
your research, but I think I'mgoing to have to leave it there.
(02:23):
Sergio, thank you so much forcoming in and being here with me
today.
Sergio (02:27):
Well, thank you for having me and for the kind
introduction.
Ashley (02:29):
And so in full transparency, you and I have
been co-facilitating aleadership development program
together for sounds, what, 300plus medical directors
nationally for the last coupleof years.
And so we've gotten to knoweach other pretty well.
And I brought you on reallybecause I know that you
understand deeply the importanceof the topic that we're going
(02:50):
to be talking about, which ispsychological safety within
teams and within organizations.
So I can't wait to dive intothat with you today.
Sergio (02:58):
Let's do it.
Ashley (02:59):
All right.
But before we do, I have aquestion.
I want to start with you and Iwant to start with your story a
little bit.
You are known for being a greatleader at Sound.
I have seen it.
I've seen people gravitatetowards you.
You do this really well.
Can you share about yourleadership journey through
critical care and how it shapedyour philosophy as a leader?
Sergio (03:18):
Absolutely.
And I would start by sayingthat it's an ongoing journey.
and that there's alwayssomething new to learn in being
a better leader.
And that a lot of my journeyhas been kind of dictated by
curiosity, by trying to learnnew things.
And I had the opportunity toserve as a chief fellow when I
(03:42):
was in training.
And I originally thought thatwas a distinction, an honor, and
that I would be scheduling thefellows and helping with the
conferences.
But quickly I realized that thereal hard part of leadership is
dealing with people.
And there were a whole bunch ofsituations that even in that
two-year fellowship arose that Iwould have not anticipated and
(04:06):
that I'm sure some I've handledvery poorly, but I tried to
learn from and some I handled alittle bit better and really
started understanding thatleadership is at the end about
helping people move in a betterdirection.
Mm-hmm.
serving people, and thatmanaging is easy sometimes.
(04:26):
You can lead up, and this iswhat you should do as a good
manager.
But dealing with the people isnot always as easy for many,
many reasons that we all know.
And from there, I went intoacademia, very quickly became
the program director of thefellowship program.
So now I was leading thetraining program.
(04:47):
And very similarly, a lot of myactivities changed were related
to scheduling the fellows, torunning conferences, to helping
people do research.
But the hard part was dealingwith the people.
When you had a difficultpersonality, when you had a
difficult relationship among twoof your fellows, or your fellow
(05:08):
got yelled by the CT surgeon,Then the fellow yelled at the
intern.
And that was really the hardpart.
And as a nerd and intensivist,I like to read.
So I started reading a lotabout topics that were not
medical.
Topics about leadership, aboutpsychology.
(05:29):
And started expanding kind ofmy toolkit of things that I
could apply at the bedside.
And that led me...
to become trained in Lean SixSigma, became a black belt.
And it totally changed the wayI was thinking about medicine at
that time.
And then I landed a job withwhat was then the intensivist
(05:50):
group, which quickly became partof Sound Physicians.
And for the last decade, I'vebeen serving as the chief
medical officer of a veryrapidly growing critical care
team.
And once again, it's all aboutthe people and how can you serve
them and how can you help themgrow And that has just been, I
would say, an endless source oflearning for me.
Ashley (06:12):
Yeah, yeah.
I think that one thing I loveand that I'm hearing is a lot of
curiosity.
You carry a lot of curiosity,more than many people I know, to
just keep that learningprocess, keep open to that, keep
reading.
Let me ask you, I want to segueinto this concept of
psychological safety.
And one of the phrases that Ilove that I've heard you use in
(06:33):
our work together is thisconcept of a fearless ICU.
And I think it's a powerfulterm.
If you could describe what youthink that means in just three
words, what would they be andwhy would they be that?
Sergio (06:46):
Well, that's a great question and a hard one.
Yeah.
But if I had to choose threewords, I would say curious,
safe, And accountable.
Curious because I reallybelieve that a fearless ICU is
all about learning.
Learning how to do thingsbetter, but also learning from
(07:07):
our mistakes.
It is impossible to delivercomplex care to critically ill
patients on a daily basis andnot make mistakes.
Ashley (07:17):
Right.
Sergio (07:18):
Does not happen.
Yeah.
So in a fearless ICU, we...
don't want to make mistakes,but when they happen, we embrace
them as a learning opportunityand we can talk about it.
So that leads me to the secondword, which is safe.
I feel safe to not only takerisks as a leader or as a nurse
(07:38):
or as a physical therapist andgiving my opinion, but I also
feel safe in bringing upproblems to the team and to not
be criticized, ostracized, ordemeaned but to be thanked for
bringing up a problem that wecan all work on together to move
in the right direction.
So that's the safety part,which ultimately also plays into
(08:02):
another safety area, which ispatient safety.
If teams can't talk aboutmistakes, it's very difficult to
provide safe care.
And finally, I saidaccountability.
And this is important becausewhen clinicians, especially in
the ICU, which is a high stakes,high adrenaline environment
(08:23):
here, psychological safety, theyimmediately go to like a, oh,
it's a kumbaya thing and like asoft thing.
And it's not about that.
We still want to be accountableto each other.
And what we're looking for isthe highest performance.
But it's come to therealization that without us
having that learning experience,growth mentality without making
(08:46):
it safe and inclusive foreverybody, we cannot perform at
the highest level, period.
We just can't.
So accountability is important.
The goal is to perform at thehighest level.
These are very sick patientsand things we decide can really
make the difference betweensurviving and not surviving.
(09:07):
Sometimes there is no chancefor surviving, but we still want
to perform at a high level andmaking sure that we can take the
family through that process inthe most compassionate way.
So I think that going back tothe three words, it would be
curious, safe, and accountable.
Ashley (09:24):
Right, right.
I love that you added theaccountability because you're
absolutely right.
In leaders that I've workedwith, one of the biggest
misconceptions I hear is, aboutthis concept of psychological
safety is that they think it'ssomehow going to be coddling
people.
It's going to be too easy onpeople.
You know what, we're going tojust, you know, be soft and give
(09:44):
them everything they want.
They don't realize that that'sexactly the opposite of what
we're talking about.
We're talking about maintainingthose high performance
standards, but making anenvironment where that can
actually function.
Yeah.
Yeah.
Why do you think it's socritical in clinical
environments that this exists?
Sergio (10:03):
Critical care is probably a magnified example of
healthcare.
But if you took healthcare as awhole, the reality is that it's
a complex environment with highstakes.
And as a complex environment,we know parts of what we need to
do, but we don't always knoweverything we need to do.
(10:23):
It's not like if you're bakingbanana bread, there's 10 steps,
exact proportions.
And if you do that, you'reokay.
In critical care, you might dothe first 10 steps right, and
the outcome might still be anegative one.
So it's a complex environment.
As such, you're constantlytrying to learn, but you also
have a lot of moving parts.
(10:43):
And if those parts don't feelsafe to interact, to show up in
their best version, to givetheir opinion of what might
help, or to say, I don't know.
Could you show me?
I'm not sure what to do.
Can you help me?
I just made a mistake.
We need to fix this.
(11:04):
It's impossible to deliverhigh-level care consistent.
And it's very interesting thatin medicine, we are taught that
failure is bad.
Now, there are different typesof failure.
Some of them should absolutelybe avoided 100% of the time.
Like if you go to surgery for aright leg amputation and they
(11:25):
amputate the left leg, well,that's a Never event.
That's a problem, right?
However, there are situationsin where we might fail in saving
a patient, but everything wasdone right.
So how do we learn from that?
And the ability to learn fromfailure is embedded or based on
psychological safety.
Can we talk about what we didwrong or what we could do better
(11:49):
in a safe way where everybodycan learn?
And that is the most importantfactor to provide safe care, but
also ensuring to keep evolving.
We have situations like COVIDwhere we have no idea what to
do.
Well, if you're not in apsychological safe ICU, how are
you going to learn as quickly asyou need to provide that care
(12:09):
to those patients?
And running several ICUsthrough our practice, I saw
that.
I saw some ICUs did better thanothers.
with the same amount ofinformation, the same level of
ignorance, right?
But some ICUs were safer from apsychological standpoint, and
they worked as a team to figurethings out.
(12:29):
And others were paralyzed bythe fear of failure, by the fear
of communicating.
And ultimately, the patientsare the ones who have to pay
that price.
Ashley (12:39):
You had Dr.
Amy Edmondson on your podcasttwice.
And Amy Edmondson is, ofcourse, the person who came up
with the concept ofpsychological safety through her
research and her work over theyears.
And I'm curious, because yourpodcast is really focused on
clinical care medicine, and yourlisteners are clinical care
physicians for the most part,what drove you to bring her on?
(13:00):
And why did you think that herwork was so important for your
listeners to understand?
Sergio (13:05):
That's a great question.
And I would say that The reasonwhy I brought her on is the
reason why she probably acceptedto do it.
Amy Edmondson, as youmentioned, is a professor at the
Harvard Business School.
She has done amazing researchin the area of work
(13:26):
environments, complex workenvironments and performance and
coined the term psychologicalsafety.
She has studied ICU teamsthroughout her career.
in terms of identifying whatare the factors that make one
team perform at a high levelversus a team not perform so
well.
And she's identified that themost important factor is
(13:46):
psychological safety.
Yet as relevant as her work andher findings are for the
practice of critical caremedicine, it is not discussed in
clinical arenas.
Now people are talking aboutthis concept, but when I was a
fellow, I didn't even know thisword existed.
Ashley (14:05):
Yeah.
Sergio (14:05):
When I was a young attending, starting a
fellowship, it wasn't even onthe radar of things that we
should teach the fellows.
Yet, it's probably the singlemost important thing in
performing at a high level dayin and day out.
We train critical carephysicians to be the leaders in
the ICU, but we weren't trainingthem or teaching them about the
(14:28):
most important thing theyshould build in their ICU.
We were talking about all thesediseases and mechanical
ventilators and drugs to raisethe blood pressure and diseases
like ARDS and septic shock,which is all important.
But without psychologicalsafety, it's impossible for a
team to perform at their highestpotential.
(14:50):
And that is what we all wantwhen we show up to work.
So that was the reason why Ithought it was important for her
to come and share her messageand her insights and what she
learned through years ofresearch.
And I believe that that's whyshe also thought it was
important to talk to a veryclinical audience because she
recognizes that it's almost likeparallel worlds.
Ashley (15:09):
Yeah.
Sergio (15:10):
And we need to connect a little bit more.
Ashley (15:12):
Yeah.
Yeah.
Did you get any feedback fromyour peers on those
conversations?
Sergio (15:18):
I did.
And when you do a podcast orwhen you give a lecture or write
something, you want it to havethe maximal quality.
But the reality is that as longas a couple of people take it
to heart and they do somethingto change what they're doing,
it's a win.
And I actually know some ICUdirectors and fellowship
(15:42):
directors who really embracedthe concept and was like an aha
moment.
We should be teaching this toour team.
We should be talking aboutthis.
One of my friends who I hadtrained and now is the head of
critical care at a largeuniversity program bought Amy
Edmondson's book for the wholeteam and they started reading
it.
So I do believe that itresonates with a lot of people.
Ashley (16:05):
Yeah.
Sergio (16:06):
And what I found also, Ashley, is that I have done a
lot of talks around the world,actually, about the fearless
ICU.
Ashley (16:13):
Yeah.
Sergio (16:14):
And I've talked about this in the United States and
different settings.
I've talked about it in theMiddle East, South America, in
Mexico, in Europe.
And what I find is that whenpeople hear the talk and the
concepts, they immediatelyrecognize something they live
every day.
(16:34):
Yeah.
But all of a sudden they have alanguage that Amy Edmondson has
created to articulate it, toexplain it.
And it's like, Yes.
This makes perfect sense.
Right.
Right.
Thank you for sharing this.
So I definitely think that itresonates with clinicians
because everybody who's acritical care clinician has seen
(16:56):
what psychological unsafe teamslook like.
Yeah.
Yeah.
Some have seen what good lookslike, but everybody has seen
what bad looks like.
And they can say, yes, I seethat.
It resonates.
Now I know there are things Ican do to change it.
Ashley (17:13):
Yeah, yeah.
Sometimes it's so much easierjust to be able to identify the
things you don't want before youcan really shape what you do
want.
Well, let's talk about mindsetbecause a lot of this is about
that, right?
That shift of mindset becausewe know that most clinicians are
trained to lead with authority,with certainty, with expertise,
(17:34):
even perfection if we go downthat road.
But this takes a little bit ofa shift.
So how do you help yourclinical leaders shift their
mindset and lean a little bitmore into some of the behaviors
that psychological safetyrequires, like being a little
more vulnerable, being a littlemore open?
How do you do that?
Sergio (17:53):
Yeah.
Well, the best way to shiftpeople's mindset is to ask
questions and asking questionsthat lead them to the answer you
want.
I think that's a great way tostart.
But also a lot of times it'sjust showing them or
exemplifying the behavior,obviously, but also pointing out
(18:14):
to our leaders or to ourcolleagues examples of why
psychologically unsafe behaviorsare detrimental to our patients
and to our team.
And it's a little bit of acombination of asking questions,
role modeling, and giving thepeople feedback of, the damage
(18:35):
that bad behavior does in thatrespect.
Ashley (18:38):
Right, right.
Yeah, that makes sense.
Sergio (18:40):
And talking about it, obviously.
We talked about the Furious ICUin our leadership meetings.
We talk about it in clinicalsettings and fellowships now.
So also, the first step is toidentifying we have a problem
and talking about it and tryingto provide some solutions.
And again, some people embraceit, but not everybody.
That's okay, as long as we'removing the needle.
Ashley (19:02):
That's right.
That's right.
Critical mass.
All right.
Is there a moment that you canshare that you've actually seen
a team have a breakthrough inpsychological safety and what
made that possible in thatexample?
Sergio (19:17):
So as a breakthrough, I would say that studies have
shown, and a lot of thesestudies, again, come from Amy
Edmondson's team, that thequality in a leader that most
likely correlates topsychological safety is being
inclusive.
Ashley (19:32):
Okay, yeah.
Sergio (19:32):
So breakthroughs I've seen in clinical care when
they're rounding and the newnurse doesn't really speak up
during rounds.
And the intensivist who'sleading the rounds might say
something like, Ashley, I knowyou're new to the team.
You've been very quiet duringthis patient's presentation, but
(19:56):
you are helping care for thispatient.
I really want to hear youropinion.
It's important for us.
What do you think we should bedoing?
Or is there something that weshould know?
And it gives them permission tocontribute.
And I think, especially inmedicine, which is very
hierarchical sometimes, that'shard for new people.
(20:16):
A similar breakthrough might bein a team meeting among
physicians.
When there's one physicianwho's very quiet about a new
change that you're trying toimplement to the ICU.
And again, you might say,Sergio, You've been very quiet.
I can't read if you're inagreement or disagreement, but
either way, your opinionmatters.
(20:36):
Could you share what you'rethinking with us?
Bring them in, invite them totalk with you.
That is the best way I believeto break through.
The other breakthrough thatI've seen in different settings
is how a leader handles badnews, right?
Do we shoot the messenger?
Ashley (20:57):
Right.
Exactly.
Sergio (20:59):
And then obviously people are going to say, well,
I'm not talking next time.
Or do we acknowledge theproblem and thank the messenger
for bringing it up to the team?
Ashley (21:08):
Right.
Sergio (21:09):
When they question something you are doing as a
leader, obviously your initialreaction is to be defensive, but
you might say, you know what?
I hear your point.
Thank you for bringing this up.
Let's talk about it.
So that is a great way ofcreating a small breakthrough
with psychological safety.
Ashley (21:28):
Isn't that what Amy Edmondson calls responding
productively, right?
When somebody does take a riskand come to you with something,
the way that you respondmatters.
Absolutely.
You know, the other thing thatpops into my mind is we've
talked in the past aboutpeople's experience of
psychological safety isdifferent.
And there are different factorsthat attribute to that.
(21:49):
And just being aware of thatfact, whether it be hierarchy,
whether it be are theynon-native English speakers,
gender, all kinds of things thatcan get in the way where we
might assume their psychologicalsafety, their experience of it
might be different.
Sergio (22:05):
Absolutely.
And again, there are studies inmedicine.
about this and on averagephysicians are going to feel
safer in the ICU than nurses whoon average feel safer than the
respiratory therapists and itmight have to do with perceived
roles with number of people withyears of experience it was a
(22:25):
lot of of issues but you'reright and we have to acknowledge
that as a executive physicianwho's a middle-aged white male I
have a lot of privilege and Ifeel very safe, but I don't have
to assume that everybody on myteam feels the same thing I
(22:45):
feel.
Ashley (22:45):
Right.
Sergio (22:46):
Right.
And being able to recognizethat is important.
And the way you slowly movethat needle is by making sure
that everybody is included andfeel they belong to the
Ashley (22:58):
team.
Right.
Exactly.
Well, let me ask you this.
We were talking a minute agoabout the data that supports
this.
And I think that's a reallyimportant point because too many
people might have themisconception that this is a
soft science.
But this is not just a softscience, right?
There's more and more studiesthat have been done in
healthcare that demonstrate theimpacts to really measurable
(23:20):
outcomes, right?
Safety, quality, teamperformance, morale, retention,
all those factors.
What measurable impacts haveyou seen in your experience on
those kinds of outcomes whenpsychological safety is
prioritized in a team?
Sergio (23:37):
Well, I think that one of the things that is very
evident is the number of safetyreports that a team will submit.
If you have two ICUs and onereports on average, let's say
six to seven patient safetyevents every month, and the
(24:00):
other ICU reports zero, yourfirst thought is that I want to
be in the second ICU becauseit's safer.
My thought, based on the data,would be I want to be in the
first ICU because in both ICUsthere's problems, but only the
first ICU talks about them.
Ashley (24:17):
That's right.
Sergio (24:18):
And I always say with patient safety, the ultimate
measure of clinicians feelingsafe is when they self-report
patient safety events, which isvery hard, right?
When they self-report, can wereview this case I was involved
with?
I think I may have made amistake.
That is the ultimatemeasurement of psychological
(24:39):
safety, and it's hard toachieve.
But also, there are very goodstudies outside of medicine.
Google did a massive studywhere they looked at what were
the determinants ofhigh-performing teams, and this
is performance-measured bydollar signs, right?
Which teams deliver the highestreturn, the highest product,
(25:02):
and the single most importantfactor by far was psychological
safety.
Does the team members feel safeto ask questions, to interact,
to show up at their bestversion, to take small risk?
So it's there, you can see itin different outcomes for sure.
Ashley (25:20):
Well, let's make it really clear.
If you're on that team in theICU that maybe doesn't have as
great a psychological safety asthe other one, what do you think
signals to people that it's notsafe to speak up?
What kinds of things would behappening?
Sergio (25:36):
Part of it might be learned behavior from previous
jobs.
A lot of times, new members andteams in health care constantly
change, not only over time, buton a daily basis, this concept
of teaming, right?
People show up as a differentteam every day in some respects.
So they might have learnedbehaviors from other teams,
(25:57):
which unfortunately is veryprevalent in healthcare that we
have psychological unsafe teams.
And maybe they saw somebodyelse get into trouble for
bringing up a problem, so theydon't want to bring it up.
Or they presence that somebodyasked a question and got reamed
or got demeaned or gotridiculized for not knowing
(26:18):
something.
Or there was a difficultpatient interaction and the way
the people involved reacted wasvery negative.
So these are all things thatwould push me as an individual
to not take that risk.
I don't want to be seen asincompetent.
So I'm not going to ask if Idon't know.
(26:39):
I don't want to be seen asdisruptive.
So I'm not going to say, well,maybe we should do this
different.
I don't want to be seen asnegative.
So I'm not going to say we havea problem.
And these are just normal humanbehaviors that we all have.
But if we are in a businessthat's here just taking care of
critically ill patients, you gotto put what's best for the
(27:00):
patient first.
Ashley (27:01):
Yeah.
And what's the cost of thatsilence in your mind?
What is the cost?
Sergio (27:05):
It's death.
Death for the patient.
Death for other people.
When you mentioned the cost ofsilence, there's a lot of case
studies about NASA and the SpaceShuttle Challenger, I think it
was, or Columbia.
I don't remember which one.
That obviously exploded on theway back and one on the way up
(27:26):
and one on the way back andkilled seven astronauts.
Ashley (27:30):
Yeah.
Sergio (27:31):
When they actually investigated what had happened,
Ashley (27:34):
What
Sergio (27:34):
they found was that there was a pervasive, unsafe
psychological environment inNASA and that people who knew
that there was a problem did notfeel empowered or did not feel
capable of speaking up to theright person.
So it leads to death.
We see it in medicine.
There are famous cases of wrongside surgery, giving somebody a
(27:55):
medication that they'reallergic to.
Now, there's a lot ofsafeguards in place for that now
with checklists and all that,but every time they reviewed one
of these seminal cases, therewere people involved in the care
that thought something waswrong, but didn't feel safe to
speak up.
Right.
So the consequence is death.
Ashley (28:15):
Yeah.
Yeah.
Truly.
Yeah.
Sergio (28:17):
Truly death.
Yeah.
Ashley (28:19):
Wow.
Wow.
Well, what is your way to lookat a team if you're going out
and gauge where they're at intheir level of psychological
safety?
What kinds of or signals orbehaviors helps you see where
they are.
Yeah.
Sergio (28:36):
So one of the things that you can observe very
quickly is how people contributeto the conversation.
If there are some team membersthat are always silent, it
immediately makes you wonder,okay, do these people feel safe
to talk?
Because at the end of the day,everybody knows something that
(28:59):
you don't know.
Everybody knows something thatsomebody else doesn't know.
So when you're trying to workas a team, you have to have, you
always have something tocontribute.
Ashley (29:08):
Right.
Sergio (29:08):
No matter what the role is.
So when you see silence on arepeated basis or when you see a
team get bad news and there'sno response.
Right.
Okay.
You wonder, is it really nobodyhas any questions?
We just changed the way we runour call schedule and there's no
questions.
(29:28):
Yeah.
Right.
No, this is an unsafe team.
And then also, obviously, whenteams have a death or a
difficult clinical situation ora mistake or a problem, how they
react, that can be very tellingin terms of the level of
psychological safety that thereis.
(29:50):
A low level would be somebodybeing berated during a
resuscitation for not doingsomething fast enough.
you got to take care of thepatient, but that's not the time
to berate somebody or howpeople respond to questions.
Like something along the lines,you should know that is not
(30:11):
psychological safe.
Ashley (30:12):
Right.
Sergio (30:13):
Right.
Our job is to make sure thatthey, that they learn it.
Ashley (30:16):
Right.
Sergio (30:16):
And if somebody asks a question, they should be
applauded for asking thequestion.
Ashley (30:20):
Right.
Sergio (30:20):
Because they're wanting to do their job better.
And if they don't know, theyshould ask.
Right.
Ashley (30:25):
Yeah.
Sergio (30:26):
Um, In terms of psychological safety also, if
somebody can point out thatsomebody's about to do something
that might be dangerous in aproductive way, how that person
responds, if they're defensiveversus you're right, thanks for
pointing that out for me, that'sa psychological safe
environment.
(30:46):
And what I would also say thatit's no different in families
and and relationships.
It's true.
You might not get a goodpicture just on a brief
interaction.
Right?
We all know perfect couples whothen totally, right, become
among our friends and you don'tknow the tip of the iceberg that
(31:09):
you see.
So you have to be a little bitmore embedded in the team to
really appreciate how the teamfunctions.
Ashley (31:17):
Right.
Sergio (31:17):
So a lot of my experience insights into where
teams are safe or unsafe mightbe talking in more depth with
members.
But just from observing themsometimes, you don't always
tell.
True.
But like I mentioned, when yousee those telltales, okay, you
say this is probably a team thatis safe.
(31:38):
This is probably a team that isnot as safe as they should
Ashley (31:42):
be.
Yeah, there are clues.
There are clues.
I agree.
For sure.
And I think this is a majorproblem.
And unfortunately, I think toooften the aspect of unsafe teams
are what we're seeing more.
We're trying to turn the tide.
We're trying to get thatlanguage out there, that
awareness.
What do you think are some ofthe biggest cultural or systemic
barriers to this that you seein either the ICU setting or any
(32:05):
clinical setting?
Sergio (32:06):
I'll answer that question through the lens of the
ICU because that's what I knowand what I believe.
I would say that one of the bigbarriers is What we've learned
before.
Ashley (32:16):
Yeah.
Sergio (32:17):
Right.
It's almost like it'sgenerational trauma that keeps
going forward.
Right.
Yeah.
We grew up in a medicine hasalways been about not making
mistakes.
Ashley (32:30):
Right.
Sergio (32:31):
And the idea of the superhero.
Yeah.
Ashley (32:35):
Yeah.
Sergio (32:36):
Superheroes are not usually vulnerable, right?
Ashley (32:38):
Right.
Sergio (32:39):
So if you had a bad outcome in a case and you would
present as a fellow in M&M,instead of trying to learn as a
team, it's almost like theanswer is always, I will do
better next time.
Ashley (32:51):
Right.
Sergio (32:52):
So you're taking the blame.
Right.
So you bring that baggage withyou.
So that's the first bigproblem.
Second barrier is I don'tbelieve that most clinicians
have the framework and languageto talk about this and to move
the needle productively.
These are skills, right?
It's not like leaders are, wetalk about this all the time.
(33:12):
They're not born.
It's not like, okay, this is aninclusive leader from birth.
And this is a leader who justcreates chaos everywhere they go
from birth, right?
No, these are learnedbehaviors.
And to learn them as a skill,you have to have the language,
the framework, and you have totalk about it.
which again, I mean, if youwere to look at critical care
(33:35):
training programs, probably 10years ago, I would say zero
talked about this topic.
Now, I would say it's a smallpercent, but the majority of
trainees get to the ICU withoutany real discussion about these
topics.
The last barrier I would say isthat We always make the analogy
(33:59):
of the ICU team as being asports team, right?
Or we're high-performing,depending, I mean, which sport
you like and which era you grewup.
I trained in Chicago in theMichael Jordan era, so you would
talk about the Bulls as theultimate team, right?
The reality is that we don'thave that in the ICU because
every day I show up to the ICU,it's different people.
(34:19):
Some people I'm more familiarwith, but some people I might be
meeting for the first time.
And you have to create apsychologically safe environment
all the time, every day, right?
Get to connect with people whoyou don't know very well in a
safe manner.
And that's a barrier, but it'ssomething we need to learn
(34:41):
because that's just the realityof healthcare.
Ashley (34:43):
Yeah, yeah.
One thing I thought about whenyou were talking too about how
this is a skill, right?
This is something you candevelop.
I think it is about learning asmuch as it is about unlearning.
old behaviors, old ways ofthinking, old entrenched
anxieties and that baggage thatwe bring into it, then that's
hard sometimes.
But at least acknowledging thatthose things have existed, I
(35:05):
think is really important.
Sergio (35:07):
Absolutely.
Ashley (35:08):
To then be able to take that next step.
Sergio (35:10):
Yep.
We have to outgrow old modelsof leadership, old models of
performance, old models ofteamwork, for sure.
Ashley (35:20):
Yeah, yeah.
Well, you, I think, are reallyin a unique position because
you're a practicing physician,but you're also a chief medical
officer, right?
And that bears a wholedifferent sort of
responsibility.
So as that level of leader,what specific actions do you
feel that leaders within yourcare need to take to create and
(35:42):
sustain a psychologically safeculture in their groups?
Sergio (35:46):
You know, Ashley, from working with me that I like
three, so I'll give you three.
where you are in your journeyor where you are within your
organization, whether you hold atitle or not, these three
behaviors can help promotepsychological safety for a team.
Number one is to frame the workappropriately.
(36:08):
What do I mean by that?
When we were taking care ofCOVID patients, we had to
acknowledge that, yes, thismight be dangerous for us.
Yes, we have no idea.
where this is the right thingor the wrong thing to do for the
patient.
So there are all these limits.
That's being vulnerable.
So acknowledge the work.
But also when you have veryclear deliverables that are
(36:33):
expectations, say that to theteam very clearly.
This is what we expect.
This is what for today.
This is the goal.
This is what I expect from theteam members.
This is how we can make thishappen.
So frame the work.
very, very accurately in termsof what's expected, but also
what's unknown or what might beproblematic.
(36:57):
Number two is respondappropriately, like you said,
and you talked about AmyEdmondson emphasizing this.
What do I mean by that?
If somebody does somethinggood, recognize that in public,
right?
If somebody does somethinggood, that does not conform with
the norms of the team, talk tothat person in private, but
(37:19):
immediately.
If somebody asks a question,answer the question without
demeaning the person.
If somebody brings up aproblem, acknowledge the
problem, thank the person forbringing it up, and then take
care of it.
How we respond to bad applessends a big message.
If we have a team member thatis constantly demeaning others,
(37:44):
being unprofessional, and weallow that to go on and go on
and go on, the team's not goingto feel safe.
And eventually other people aregoing to assume that's allowed
and they might do it as well.
So responding appropriately togood behavior, to bad behavior,
to bad news, to good news issuper important.
And it always sends the signal,right, to others.
(38:07):
And finally, the third is aboutbeing inclusive, which really
means inviting people toparticipate.
Constantly inviting people toparticipate, but also valuing
what they have.
Now, if I'm in charge of makinga decision, I can invite to
give me your opinion.
It doesn't mean that I have todo what you say, but if I
(38:30):
acknowledge your position oryour opinion as a valid one and
we take it into consideration,
Ashley (38:35):
I'm
Sergio (38:36):
including you in the conversation.
And then you will feel that youbelong to the team because
eventually they will follow youropinion, right?
So I think those three things,framing the work appropriately,
responding productively, andinviting people to participate
are three things that we can alldo, right, on a regular basis
(39:00):
to move the needle there.
Ashley (39:02):
Yeah, yeah.
And I think on that last pointabout Listening to people's
points of view, I think a secondpart to that was once you've
taken in their point of view andyou validate it, there's
follow-up.
There's a loop there that Ithink sometimes is whether or
not anything happened from whatthey wanted to say, but just
recognizing and following upwith them so that they
understand that something wasactually done with it, I think
(39:23):
can be also very much a part ofthat.
Sergio (39:26):
Absolutely.
Ashley (39:27):
Yeah, yeah.
I think that's great.
Now let's get tactical.
You've got one leader in frontof you, maybe a newer leader.
or somebody who really wants tostart doing this today, start
doing it well, what's the firstthing that you think they should
do?
Where should they begin?
Sergio (39:45):
Inviting the people who don't talk to share their
opinion.
Ashley (39:50):
Yeah.
Why do you think that one inparticular?
Sergio (39:53):
Because it lowers the decibels of tension and
immediately signals to the team,my opinion is valuable.
And also...
I share this because one of themost common things we do in the
ICU is we do clinical rounds.
So the day usually starts, youget there, you get signed off
when the person was there beforeyou.
(40:15):
At night, let's say, you kindof start seeing patients and
then at a given time, dependingon the ICU, eight, nine, it
already gets together at one ofthe beds and we start talking
about each patient.
So there's a group of peoplethat are talking about the
patient.
And if somebody's not sharingthat you might not have time to
every single time have everybodyone's opinion.
(40:37):
But if you notice that somebodyis very silent, asking them for
an opinion and telling themthat your opinion is important
and valuable, signals to theteam safety.
So that's the first thing Iwould do.
The same example would be in ateam meeting with colleagues.
(40:57):
As you know, and you workedwith us for many years,
collaborated with Sound, we havemultiple practices around the
country.
And usually the team ofclinicians that includes
physicians, APP, CRNAs, and insome instances, nurses might
have a team meeting.
And maybe the director, theprogram director is sharing a
(41:18):
new demand from the hospital,something the hospital wants us
to do, which you immediatelythink is a new brick on their
backpack.
Ashley (41:24):
And
Sergio (41:25):
now they want us to do this, right?
Everybody's rolling their eyes,but nobody says anything.
Or everybody talks and thensomebody's silent.
Ashley (41:33):
Yeah.
Sergio (41:34):
You know that they're not feeling safe to share or
they feel that they share it's awaste of time.
Now, we might not be able tochange what needs to be, what
they've asked from us.
Right.
But people can still talk.
share what they feel and why,and maybe you can show them by
asking them some questions thatmaybe they're looking at through
the wrong lens.
(41:54):
So that's another example.
Invite them to participate.
20 members not talking at all.
Joe, I noticed you're verysilent.
We really value your opinion.
Could you share with us whatyou're thinking?
And it's possible that Joedoesn't say anything that time,
but you make that note and nexttime.
Ashley (42:13):
Yeah.
Sergio (42:14):
You ask them.
And if you're running a meetingwith a small number of people,
you should be checking, right,who's talking and who's not
talking.
Ashley (42:23):
Right.
Sergio (42:23):
There's a fascinating study from the MIT group many
years ago that looked at theperformance of teams.
And these were smaller teams,like three to five people
working on creative tasks.
And what they found is thatEqual speaking time
Ashley (42:39):
was
Sergio (42:40):
one of the most important factors, right?
And it speaks to psychologicalsafety.
Everybody felt safe to givetheir opinion.
So when you have more angles atit, you can find more creative
solutions.
Ashley (42:52):
100%.
And what I was thinking about,and it's so great that you
brought that up, is I think alot of leaders, especially young
leaders, feel the need to talka lot.
Right.
They're driving the meeting.
They've got to be the ones outin front.
And there is power in maybesetting it up, but then stepping
back and letting the otherstalk.
And that's, I think, a perfectexample of
Sergio (43:11):
that.
Absolutely.
Absolutely.
Ashley (43:14):
All right.
Well, I've got a couple morethings for you before I cut you
loose, Sergio.
So I want to think about you.
If you were to look back, lookat yourself 20 years ago.
What's something that you wouldsay to yourself or something
you wish that you would havelearned earlier in your career
that maybe you You couldn't useback then.
Sergio (43:33):
It's funny that that question comes now because you
just mentioned me as a youngleader.
Ashley (43:37):
Okay.
Sergio (43:38):
I would say listen more, talk less.
Yeah.
And about listening, what Iwould say is listen with the
intent of learning.
Ashley (43:50):
Right.
Sergio (43:52):
And I look at some of my first leadership, quote
unquote, leadership meetings.
Ashley (43:57):
Right.
Sergio (43:57):
Which I thought I had.
nailed it then I realized all Idid was talk yeah what a
failure right and I stilleverybody likes to talk and you
know me I like to share ideasand talk but I would say that
talk less listen more yeah isthe most important lesson I
(44:18):
would teach my younger self yeahbecause it makes such a
difference right
Ashley (44:25):
yeah yeah well absolutely I love that All
right, so last thing I want todo with you, if you're down for
it, if you're game, I'm going toask you my quick set of
questions I like to ask peopleat the end.
How do you feel?
Are you good?
We're ready?
Okay.
So the first one is, what's oneword to describe your
leadership style?
Sergio (44:45):
Curious.
Ashley (44:46):
I like that.
What is a leadership value thatyou won't compromise on?
Sergio (44:51):
Kindness.
Ashley (44:53):
Yeah, that makes sense.
What's the most important habityou've built as a leader?
Sergio (44:59):
Ah,
Ashley (45:00):
okay.
Why that?
Sergio (45:04):
Because it's like networks.
There's strong ties and weakties.
And when you read a lot ofdifferent topics, it's almost
like you have a big network ofweak ties that all of a sudden
give you answers or show youpaths.
That if you just read medicine,you would have never found.
Right.
(45:25):
So I think that expanding yourbrain by reading a lot and
different things can really helpyou in your day-to-day work.
Ashley (45:32):
Love it.
Love it.
All right.
So what is one thing that helpsyou reset after a tough day?
Sergio (45:38):
My dogs.
Ashley (45:42):
Nice.
What was it?
but my
Sergio (45:45):
kids are all gone and my granddaughter is in New York
but yeah my family my dog mypets I think especially the dogs
because they're with me rightnow and they're I wish that we
all behave like them they're sonoble right and They always seem
to be living in the moment.
Ashley (46:04):
They do.
Sergio (46:04):
Which I believe is very resetting for me.
Ashley (46:08):
Yeah.
All right.
What is something you used tobelieve about leadership that
you no longer do?
Sergio (46:14):
That you have to be the smartest person in the room to
lead.
Ashley (46:19):
Yeah, for sure.
What is the biggest lesson thatyou've learned from your team?
One
Sergio (46:25):
of the things I've learned from my team that has
been very humbling is that Don'tassume that what you value is
what other people value.
Ashley (46:32):
Yeah, yeah.
Sergio (46:33):
And I think it's true for patients too.
Ashley (46:35):
Agreed.
That's a good one.
What's your favorite questionto ask in a one-on-one?
Sergio (46:41):
About books.
The book that has influencedyou the most or what book have
you read lately?
And that's very, I want tolearn, but also I'm looking for
more things to read.
Love it.
Ashley (46:50):
Love it.
Well, on that topic, what's abook or resource that you think
every physician leader shouldknow about?
I
Sergio (46:56):
have found that Meditations by Marcos Aurelius
is a phenomenal read and I readit over and over again.
Really?
And what it's taught me is thatif the most powerful person on
earth at that time
Ashley (47:12):
was
Sergio (47:14):
so humble and really thought of leadership as a call
to serve others, who am I toargue?
And it's a great example of howto really Lead by trying to
improve yourself, but also byrecognizing that the value in
leadership is not in what youachieve, but in what you achieve
(47:36):
for others.
Ashley (47:37):
Yeah.
All right.
Last one.
One thing every physicianleader should try this week.
Sergio (47:48):
To include, invite somebody to participate in a
meeting or in a clinical roundsor in a patient discussion.
Ashley (47:56):
Love it.
Love it.
Well, Sergio, thank you somuch.
I've so appreciated you beinghere.
I appreciate your thoughts,your wisdom, your candor.
Always appreciate it.
And
Sergio (48:07):
as
Ashley (48:07):
a leader and as a human.
The
Sergio (48:09):
same here.
And I appreciate having theopportunity to talk with your
audience and on your podcast andalso...
Appreciate the opportunity thatwe've had over the last couple
of years to partner together andteaching, but really in
learning together, which isultimately the most important
thing.
Ashley (48:24):
Agreed.
Agreed.
My thought is you are such adelight to work with.
You really are, Sergio.
I appreciate that so much.
I love sharing that teachingspotlight with you and agreed.
I've learned so much from you.
So I hope you come back.
I know we can find other thingsto talk about.
I love your insights and yourthoughts.
So thank you so much.
Sergio (48:41):
Thank you.
Ashley (48:42):
All right.
Take care.
For everyone listening, I hopeyou found this conversation with
Dr.
Zanotti as thought-provoking asI did.
His perspective on curiosityand the quiet signals of
psychological safety in teamsreally underscores how
leadership is less about knowingall the answers and more about
creating the conditions whereothers can speak up and show up
(49:05):
and grow.
So if you're a clinician leaderwondering where to start,
remember Serge's advice.
Invite somebody into theconversation, especially the
quiet ones.
Psychological safety startswith those small, intentional
acts of inclusion.
Thanks, everybody, forlistening.
And if you found value intoday's episode, please consider
sharing it with a colleague orleaving a review.
(49:28):
And if you're not alreadysubscribed, hit that follow
button so you don't miss futureepisodes.
Thanks for being here.
Take care, and I'll see younext time.
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