Since writing my blog post on the Quality and Safety BMJ article on the Deaf Effect, I’ve been thinking a lot about what people concerned with patient safety and the impact of toxic hierarchy can do about it. In Britain, they are trying to reward people who speak up. Clearly that should be done in North America and all over the globe. But we can think even more about this issue. Jones and Kelly describe what happens when employees use their voices and are ignored. When they take risks and no one acts to prevent harm. . Silence not voice is encouraged by high level inaction. This encourages a sense of futility and risk aversion and then self-silencing becomes contagious and a cultural –not just an individual – habit. High level inaction in the face of voice – what Jones and Kelly call the Deaf Effect (we might think of this as the sounds of silence) — is thus one of the things that instills the habit of silence. There are other factors that encourage silence rather than voice.There are other factors that encourage silence rather than voice. (Anyone interested in this subject should read Albert O. Hirchsman’s classic Exit, Voice and Loyalty). I think of these things as the Signs of Silence. They are subtle messages that tell people to stay in their place and not to express concerns or use their voices. They offer not only an opportunity to analyze the current status quo but to change it – by doing something to challenge it, something as simple as some of the things I describe below. Consider, for example, the way interprofesional or inter-disciplinary patient rounds are all too often conducted in hospitals today. I have discussed such rounds in an essay on Teams, Teamwork and Team Intelligence in First Do Less Harm, where I describe a line up outside a patient’s room where an attending physicians stands talking to a group of physicians-in-training with three nurses standing behind her. She has her back to the nurses and never turns to them or suggests they be included in the group. Ethnographer Elise Paradis has studied so-called interdisciplinary rounds on ICUs and describes circles of physicians that remain impenetrable to non-physician staff who are supposedly participating in rounds. Are these rounds really interprofessional? Or consider the very common situation that occurs on wards every year when new graduate nurses come arrive on the job. Instead of being welcomed by experienced colleagues, they are often made to feel they should not be asking so many questions. Instead of offering to support these new grads, experienced nurses give them the distinct impression that they are an unwelcome burden and they overhear nurses wondering why they just can’t “hit the ground running?” Canadian nursing professor Judy Boychuk Duchscher has written about this eloquently in her work on Nursing the Future. Or what about this. An RN is precepting an NP student. The student notices that some attending physicians aren’t washing their hands before or after they see patients. The student mentions this to his preceptor. Her response? She tells him that’s just how things are. “You don’t want to viewed as a know-it-all, do you?” He feels demoralized and wonders whether he made the right choice of profession. Or as I described in a different blog post, there’s the issue of the table and who gets to sit at it. Sorry if you’ve read this before, but for those who haven’t here’s the gist. A high level team meeting occurs at major teaching hospital. The room has a large conference table in the middle of the room, and chairs around it as well as around the periphery. Nurses and other non-medical staff always sit on the periphery. They “know,” people tell me, that the seats around the table are “reserved” for physicians and high level administrators. So yes, the team meets. But if this a real meeting of a real team or is it a team in name only, one in which people are told precisely what their place is and to stay in it?Consider, for example, the impact of the way interprofesional or inter-disciplinary patient rounds are conducted. Are all of them really interprofessional? Each of these situations and many more offer not only ethnographic evidence of the problems that must be confronted if we are to create real teamwork in healthcare. These situations offer opportunities to teach and coach, to help people re-form the healthcare team in ways that encourage voice rather than silence by eliminating the signs that encourage silence. So here is my question: What would you do? What would you do if you saw a group of physicians standing in a circle discussing a case while nurses and non-medical staff were arrayed on the periphery, unable to hear or contribute? Would you say something? Then? Later? Would you figure out a way to invite them in? What would you do if you observed an attending physician facing a line of physicians-in-training with nurses standing in back craning their necks to hear. No one invites the nurses to join the physician line-up and really participate in the rounds. Would you? What would you do if you overheard a group of nurses standing at the nursing station talking loudly about a new nursing grad. You hear them wondering why she is so slow? They wonder why she can’t hit the ground running? Would you say something about what it’s like to be the new kid on the block? Would you suggest they support rather than criticize her? Would you support her? Welcome him? Offer some help? Or what about the student who’s been told not to speak up by a preceptor? If you learned about this what would you do? Ignore it? Get depressed? Help him figure out what to do? And then there’s the famous table. If you saw this happen again and again in meetings, what would you do? A lot of things in healthcare are really hard to change. It’s hard to change reimbursement. It’s hard to get more nurse staffing on units. It’s hard to produce more primary care providers – particularly MDs. It’s hard – way too hard – to get a national health care system in the US — one that makes more sense than money. These things are really really hard. Changing culture is also hard. But the kind of change that encourages voice doesn’t depend on an act of Congress or Parliament. It doesn’t depend on millions of dollars or pounds or yen. It depends on individuals working both alone and together to establish and reinforce new patterns of behavior and politely and firmly challenge the behavioral status quo. It depends on thousands of individual choices – choices we can all make today, tomorrow and the next. I have seen people — like those I describe above — make these choices. They are small, little things but they make a huge difference. Here are some of them. Physicians make sure to invite nurses into the circle of rounds. All the time. Everytime. The attending physician is aware of the habit of exclusion and makes sure to invite nurses to stand in front of her along with physicians in training and would listen attentively to their suggestions and concerns. I have watched this “ending the silence” work at the San Francisco VA Medical Center where rounds on Patient Aligned Care Teams always include RNs and attendings and others. Attending physicians are careful to constantly invite RNs into the circle, thank thems for coming to the rounds and for any information they provide at them. Rebecca Shunk who is physician Co-Director of the Center for Excellence in Primary Care Education and her NP Co-Director Terry Keane and their colleagues in primary care are teaching residents, NP fellows and students to relate to one another and to everyone on the team in non-hierarchical fashion On the Neo-Natal Intensive Care Unit of a major hospital, an attending physician is studying what encourages nurses to participate in rounds and is trying to make sure there are behaviors in place that encourage RNS to speak up. Several years ago, I wrote a I wrote a blog post about something I’d observed in the Netherlands, when my friend Vigfus Sigurdson, a professor of dermatology at the University of Utrecht, was showing me around his hospital. He was drinking something and somehow broke a glass, which shattered on the floor. When he told the nurse, she didn’t clean up after him, she handed him a small broom and dustpan and watched as he cleaned it up himself. This was normal operating procedure in the Netherlands. He did not complain. She did not gloat. My friend and colleague Michael Gardam, Medical Director of Infection Prevention and Control at the University Health Network in Toronto, always makes it a point to tell nurses and other people he works with – including patients – not to call him Dr. Gardam but to call him Michael. Neo-natal intensivist JoDee Anderson, also a colleague and friend, constantly talks about how teamwork saves her, makes her work possible. She doesn’t do this not only in private, but in public and even on YouTube. In another blog post, I recounted another story from my friend and colleague John Chuo who is an attending neonatologist in a neo-natal intensive care unit (NICU) at the Children’s Hospital of Philadelphia. He was showing a very prominent surgeon around the ICU. They happened to pass a nurse who happened to drop a pen on the floor. The surgeon stooped down, picked up it and gave it to her. This message of courtesy trumped hierarchy. John pointed out that this has to be the new normal if we are to achieve psychological safety and patient safety. It’s a way to end what he calls “The Suffering of Silence.” How can you help end “The Suffering of Silence?” What can you do to stop the deaf effect and help people to finally listen and hear?