I’ve shared before about the nurse who only spoke honestly when the doctor in charge was away. She took me aside and told me about a patient with a severe psychotic illness who had spent months on a locked ward without real treatment. The patient refused medication. The doctor responsible for her care, whom I’ll call Dr. K, had never petitioned the court to require treatment. The nurse asked me to act as if I had found all this out myself.
That post focused on her and on why the truth is sometimes shared only quietly. This post is about what happened next — what I almost did, and what made me stop.
The Verdict
I was just a few months into my first real leadership job at a state psychiatric hospital. When I realized what the nurse was telling me, I got angry.
Not just irritated — angry.
A patient was on a locked unit, psychotic and untreated, because her doctor hadn’t done his job. To me, this was clear-cut. It was a failure of duty.
I knew exactly what steps to take. At our state facility, we had a formal disciplinary process for union employees and a medical staff committee to review a doctor’s actions. I was already planning the paperwork in my head before I got back to my office.
Here’s what matters: I had already made up my mind. I hadn’t done any real investigation. I knew what Dr. K hadn’t done, but I didn’t know why. I didn’t realize that yet.
I saw an opportunity early in my time as a leader to prove that I cared about patient care and would hold people accountable.
Something made me stop and think. I decided to wait until I could talk it over with my mentor, Dr. Pavkovic.
Four Questions
I explained everything to him — the patient, the missing petition, and my plan. I thought he would agree, maybe even be impressed.
But instead, he asked me a question.
“What do you want to happen here?”
“I want Dr. K to be held accountable,” I said.
“That’s what you want for Dr. K,” he said. “What do you want for the patient?”
I paused.
“I want her to get treatment.”
“And what happens to her while a disciplinary process runs its course?”
I thought it through out loud. Hearings, union grievances — it would take months. And after all that, the patient would still be on that unit, still psychotic, still untreated. The process I wanted to start would do nothing for the person I was trying to help.
Then he asked the question that changed everything for me.
“What do you know about why he hasn’t filed the petition?”
Silence.
“Have you asked him?”
I hadn’t. I had a verdict, a plan, and a head full of righteous anger. But I didn’t have a single fact about Dr. K’s reasons.
Notice what Dr. Pavkovic didn’t do. He never told me I was wrong or defended Dr. K. He just asked questions and let me realize that my plan would punish a doctor without helping the patient. It was classic Humble Inquiry.
The Conversation
So I went and asked.
I didn’t go in as a prosecutor looking for evidence.
Instead, I approached him as someone who truly didn’t know the answer.
“Help me understand,” I said to Dr. K. “Why haven’t you petitioned the court for involuntary treatment?”
What I learned changed everything. Dr. K had spent almost his whole career in suburban outpatient practice and joined the state hospital near retirement. In all those years, he had never petitioned a court for involuntary treatment — not once. He knew about the process, but he didn’t know how to properly fill out the forms or what a mental health court hearing was like.
He hadn’t told anyone. After all, what doctor, near the end of a long career, wants to admit, “I don’t know how to do this”?
My judgment had been about character, but the truth was about experience. I had assumed he didn’t care, but really, he just wasn’t familiar with the process.
That didn’t make the situation okay. The patient was still without treatment, which was unfair to her and, honestly, an ethical problem. I told Dr. K this and asked if he could see how his inaction had hurt her. He didn’t argue; he admitted it.
Then I asked one more question: “Would you like my help with the petition?”
He said yes.
We filed the petition together and prepared for the hearing as a team. When the day came, I went to court with him and sat beside him while he explained the reasons for the petition. The judge approved it, and the patient finally started treatment for her illness.
After that, Dr. K filed his own petitions. The disciplinary process I was ready to start would have taken months and helped no one. Our conversation took just one afternoon.
What This Means for You as a New Leader
If you’re new to leadership, or about to step into that role, here’s what I hope you’ll take away from this.
Your sense of justice can lead you to a verdict before you’ve even investigated. Psychologists call this the fundamental attribution error: we blame others’ failures on their character, but explain our own by our circumstances. As clinicians, we would never treat a patient without an exam. As new leaders, we often do the same thing with people. If you feel sure about someone’s motives, that’s your sign to go ask them.
Don’t reach for the biggest tool first. Having a title gives you access to resources such as disciplinary processes, committees, and formal authority. Sometimes, those are needed — if Dr. K had refused to see the problem or kept repeating it, we would have gone that route. But formal processes are slow and blunt. Once you start them, people stop learning and start defending. Asking a question costs nothing and keeps all your options open.
Find your own Dr. Pavkovic before you need one. We often talk about mentors as a nice career bonus, but that’s not what saved me. A mentor is a safeguard — the person you call before you act, who asks the questions your anger won’t let you ask yourself. The truth is, I didn’t choose curiosity over discipline on my own. I was ready to escalate, but someone I trusted asked me four questions that helped me see what I was missing. If you’re starting a leadership role and don’t have that person, finding one should be your top priority.
Dr. Pavkovic passed away more than ten years ago. I can’t call him now. But even after all these years, whenever I feel myself jumping to conclusions before asking questions, I still hear his voice: What do you want to happen here?
That’s what the best mentors do. They don’t just give you answers — they leave you with a voice to guide you.
One day, someone new to leadership will be angry, sure of themselves, and ready to use the biggest tool they have. Be the person who asks them that question.
If this post resonated, you might also want to read Why Psychological Safety Is Not About Being Nice, where this story begins, and Why Didn’t Anyone Tell Me? — Humble Inquiry, Part 1, about why asking real questions is the most underrated skill in physician leadership.
