It’s About Making Truth Easier to Tell
Years ago, when I was leading medical care at a state psychiatric hospital, one day, a nurse once pulled me aside while I was rounding on a unit. The ward’s medical director — let’s call him Dr. K — was away on PTO.
She lowered her voice.
“There’s a patient here who has been on the unit for months,” she said, “and she’s not on any medications.”
I asked, “Why not?”
“Because she refuses.”
In a psychiatric hospital, that answer raises an immediate ethical and legal question. If a patient has the capacity to consent to treatment or refuse it, then you may disagree with the decision, but you cannot simply keep that person on a locked psychiatric unit for months because you do not like the choice. The patient should be discharged.
If, on the other hand, the illness is so severe that it impairs the patient’s capacity to consent or refuse, then the answer is not endless waiting. The answer is to petition the court for involuntary treatment.
These situations are hard. But they are not vague. What is not ethically acceptable is a highly psychotic patient, refusing treatment, remaining on a locked unit for months, with no medication and no petition filed.
So I asked the nurse, “How sick is she?”
“Extremely psychotic.”
“Is she competent?”
The nurse was careful.
“That’s not for me to answer,” she said. Then she added, “But I don’t think a court would find her competent to consent to treatment or to refuse it.”
I asked the obvious next question.
“Then why hasn’t a petition been filed?”
She hesitated. Then she told me.
“I raised the issue a couple of months ago. Dr. K shut me down. He told me not to tell him how to practice.”
I asked, “Why are you bringing it up to me now?”
Her answer is the reason I am writing this piece.
“Because he’s away. And if you bring it up when he returns, you can say you found out on your own while rounding on the ward. That way, he doesn’t have to know I told you.”
That is what a lack of psychological safety looks like.
Not shouting, open hostility, or some dramatic act of retaliation.
Just a quiet calculation by a professional who sees a serious problem and decides that the safest path is not to speak openly, but to smuggle the truth to someone who can act on it without exposing the source.
That is not just a communication problem. It is a leadership problem.
The Real Issue Is Not Silence, but the Unspoken Truth
Psychological safety is one of those phrases that gets overused until it starts to sound soft, trendy, or vaguely therapeutic. It is none of those things.
Psychological safety can be, but does not have to be, about fear for one’s job.
The nurse in the incident above did not report to Dr. K. She was a member of a public-sector union. If Dr. K. knew that she had alerted me to the matter, there was zero risk to her job. The only consequence she would face was social friction at work.
At its core, psychological safety means that people can say what needs to be said without being humiliated, dismissed, or quietly punished for it.
They can ask the awkward question.
They can report the near miss.
They can challenge the plan.
They can say, “Something about this feels wrong.”
They can say, “I think we are avoiding the real issue.”
In other words, psychological safety is not really about comfort. It is about whether truth can make it into the room. And in healthcare, that matters more than almost anywhere else.
In many industries, when people stay quiet, money is lost. In healthcare, when staff stay quiet, patients get hurt.
The Most Dangerous Thing in the Room Is the Unspoken Truth
Thinking about psychological safety reminds me of the movie Jaws.
The shark is terrifying, yes. But the deeper leadership lesson in Jaws is not really about the shark. It is about the refusal to fully name what the shark means.
The danger and stakes are real and easily imaginable. And yet people hesitate, rationalize, and delay. They protect the town, the summer season, the politics, and the appearance of control.
In that story, the problem is not that no one knows about the danger. The problem is people know, but too few are willing to say plainly what it means and what managing it requires.
That is how many organizations work, too.
Often, people closest to the problems clearly see failing processes and the risk they create. Where there is no psychological safety, they build workarounds. But they don’t say the truth in the rooms where it needs to be said. Because everyone has already learned the cost of being the one who says it.
Why Physician Leaders Need To Hear This
This is especially important for physicians who move into leadership.
Most doctors are trained in a culture where expertise, decisiveness, and confidence are rightly valued. We gather data. We narrow the possibilities. We make the call.
We get big bucks and the blame. We are usually the highest paid member of the clinical team. We also pay big bucks to make the wrong call. No matter who on the clinical team makes a mistake, the doctor-in-charge is always named in the malpractice lawsuit.
Our decision about clinical care is the one that ultimately matters. Because we are the ones with the greatest depth and breadth of medical knowledge on the team, a clinical decision will not be a democratic one with one member, one vote.
However, your team is watching how you make those clinical decisions. They are watching what happens to the person who brings you certain truths before the decision is made.
Do you become curious or defensive?
Do you ask “What happened,” or “Who is at fault?”
Do you welcome dissent, or do you shut it down in the name of efficiency?
Dr. K may not have thought he was shaping culture when he told that nurse not to tell him how to practice. But he was.
In one sentence, he taught her something lasting: Do not question my decisions unless you are ready to pay for it.
And once a team learns that lesson, they do not stop noticing problems. They just stop bringing them to you directly.
Leaders Must Learn To Name What Is Unsaid
To me, this is the deeper leadership skill beneath psychological safety.
Leaders must learn to name what is unsaid. Not as a performance, but as a matter of habit.
That might sound like:
“I have a feeling there is more concern here than we are naming.”
“Something about this feels too quiet.”
“Let me say out loud what others may be wondering.”
“I may be wrong, but I think we are avoiding the real issue.”
“What is the hard truth here that has not yet been spoken?”
This is courage in the service of truth.
Because once the unsaid is named, the room changes.
People breathe differently. They stop performative agreement. Only then can the real work begin.
In the hospital story above, the nurse could not safely name the truth in the usual channel. She had to find a side door. That is what people do in unsafe cultures. They do not entirely stop telling the truth. They just tell it sideways. In hallways. In whispers. In side conversations. After the meeting. To someone safer.
And when truth only moves sideways, it stops being actionable. And leadership becomes blind.
How Leaders Destroy Safety Without Meaning To
Most leaders do not set out to create silence. They do it in moments.
A question met with irritation.
A concern treated like disloyalty
Reminding someone to stay in their lane.
None of this has to be dramatic to be effective.
People are always studying the team’s atmosphere.
They are learning:
What happens here when someone speaks plainly?
What happens when someone questions authority?
What happens when the truth is uncomfortable?
Their future honesty will be shaped by those answers.
Psychological Safety Is Not Being Nice
Amy Edmondson, a researcher at Harvard, studies teams. Early in her career, she studied nursing teams in hospitals. She found something strange. The best-performing hospital units reported more errors than the worst-performing ones. Not because they made more mistakes. Because they felt safe enough to talk about them. The weaker teams had just as many problems. They just buried them.
Let’s say this plainly.
Psychological safety is not about making everybody feel good.
It is about making candor safer than silence.
In fact, a psychologically safe team may be more direct, more challenging, and more demanding than an unsafe one, because people trust that disagreement will not be treated as betrayal.
The team where all meetings go smoothly, no one pushes back, and agreement is reached without friction, is often the most unsafe.
When the room is too smooth, there is a good chance the truth is not at the table.
How To Build Psychological Safety
This does not require a ten-point framework. It requires disciplined habits.
1. Respond to bad news with curiosity before judgment
When someone brings you a concern, your first reaction shapes what they will do next time.
Start here:
“Tell me more.”
“What are you seeing?”
“What feels off to you?”
“What are we not naming yet?”
That last question matters.
Sometimes your job is not just to invite honesty. It is to give language to the truth that people are afraid to say first.
2. Invite dissent before false agreement hardens
Many leaders ask, “Any questions?” when what they really mean is, “Can we move on?”
Ask better questions.
“What could be wrong with this plan?”
“Who sees this differently?”
“What concern might someone have but hesitate to say out loud?”
“If this goes badly, what will we wish someone had said today?”
Then wait.
Do not rescue the silence too quickly. Silence is often the moment when the unsaid is deciding whether it is safe to appear.
3. Debrief failure without turning it into a trial
When something goes wrong, accountability matters. But accountability and humiliation are not the same thing.
Ask:
What happened?
What assumptions did we make?
What warning signs did we miss?
What concern was visible but never fully voiced?
What do we need to change so the next person can speak sooner and more safely?
Many failures in organizations are not caused by total ignorance. They happen because someone knew, but the culture made it hard to say.
The One Practice
In your next difficult meeting, do not just listen to what people say.
Listen to what they step around.
Listen for the pause.
The softened language.
The nervous laughter.
The too-quick agreement.
The issue that keeps brushing the edge of the conversation without ever entering it.
Then, if needed, name it gently.
“Let me say what I think may be sitting underneath this conversation.”
That one sentence can change a room.
Because leadership is not just about setting direction.
One of the most important responsibilities of leadership is giving truth a place to stand.
