Lead Well MD: Transforming Healthcare Through Effective Clinician Leadership

"The Fearless ICU: Building High Performance Through Psychological Safety" with Dr. Sergio Zanotti

• Ashley Wendel, MA, Physician Leader Group

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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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Ashley:

Hi, everyone. I'm Ashley Wendel, and this is Lead Well MD, a podcast that explores how leaders can transform healthcare through emotionally intelligent, effective clinician leadership. Today's episode is one that I've been especially looking forward to. I'm joined by Dr. Sergio Zanotti. He is a nationally respected leader in critical care medicine. He's the Chief Medical Officer for Critical Care at Sound Physicians, and he's the host of the podcast Critical Matters. I brought him on the show today because few people I know understand the topic of psychological safety in clinical teams as deeply or as personally as he does. And in this conversation, we explore what it takes to build what he calls a fearless ICU. We talk about why psychological safety is essential for patient care and team performance, and how leaders can shift from authority to inclusivity without sacrificing accountability. So let's dive in. So I am so happy to have Dr. Sergio Zanotti with me today. Hi, Sergio.

Sergio:

Hi, Ashley. Thanks for having me.

Ashley:

You bet. So I wanted to share a little bit about your background. That's okay.

Sergio:

Absolutely.

Ashley:

All right. So Dr. Zanotti specializes in critical care medicine and is the chief medical officer for critical care at Sound Physicians. He's also the director of critical care medicine at Memorial Hermann, Memorial City Medical Center in Houston, Texas. And prior to joining Sound, Dr. Zanotti was the program director for the Critical Care Medicine Fellowship and associate professor of medicine at Cooper Medical School of Rowan University. You also have your own very popular podcast, right, called Critical Matters, which covers a wide range of topics related to the practice of critical care medicine. Sergio is also a member of the Alpha Omega Alpha Honor Medical Society and has received multiple awards for excellence in medical education. He was recognized with presidential citations for his contributions to the Society of Critical Care Medicine in 2008, 2014, and 2017. So amazing. And I could go on about your writing and your lecturing and your research, but I think I'm going to have to leave it there. Sergio, thank you so much for coming in and being here with me today.

Sergio:

Well, thank you for having me and for the kind introduction.

Ashley:

And so in full transparency, you and I have been co-facilitating a leadership development program together for sounds, what, 300 plus medical directors nationally for the last couple of years. And so we've gotten to know each other pretty well. And I brought you on really because I know that you understand deeply the importance of the topic that we're going to be talking about, which is psychological safety within teams and within organizations. So I can't wait to dive into that with you today.

Sergio:

Let's do it.

Ashley:

All right. But before we do, I have a question. I want to start with you and I want to start with your story a little bit. You are known for being a great leader at Sound. I have seen it. I've seen people gravitate towards you. You do this really well. Can you share about your leadership journey through critical care and how it shaped your philosophy as a leader?

Sergio:

Absolutely. And I would start by saying that it's an ongoing journey. and that there's always something new to learn in being a better leader. And that a lot of my journey has been kind of dictated by curiosity, by trying to learn new things. And I had the opportunity to serve as a chief fellow when I was in training. And I originally thought that was a distinction, an honor, and that I would be scheduling the fellows and helping with the conferences. But quickly I realized that the real hard part of leadership is dealing with people. And there were a whole bunch of situations that even in that two-year fellowship arose that I would have not anticipated and that I'm sure some I've handled very poorly, but I tried to learn from and some I handled a little bit better and really started understanding that leadership is at the end about helping people move in a better direction. Mm-hmm. serving people, and that managing is easy sometimes. You can lead up, and this is what you should do as a good manager. But dealing with the people is not always as easy for many, many reasons that we all know. And from there, I went into academia, very quickly became the program director of the fellowship program. So now I was leading the training program. And very similarly, a lot of my activities changed were related to scheduling the fellows, to running conferences, to helping people do research. But the hard part was dealing with the people. When you had a difficult personality, when you had a difficult relationship among two of your fellows, or your fellow got yelled by the CT surgeon, Then the fellow yelled at the intern. And that was really the hard part. And as a nerd and intensivist, I like to read. So I started reading a lot about topics that were not medical. Topics about leadership, about psychology. And started expanding kind of my toolkit of things that I could apply at the bedside. And that led me... to become trained in Lean Six Sigma, became a black belt. And it totally changed the way I was thinking about medicine at that time. And then I landed a job with what was then the intensivist group, which quickly became part of Sound Physicians. And for the last decade, I've been serving as the chief medical officer of a very rapidly growing critical care team. And once again, it's all about the people and how can you serve them and how can you help them grow And that has just been, I would say, an endless source of learning for me.

Ashley:

Yeah, yeah. I think that one thing I love and 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 learning process, keep open to that, keep reading. Let me ask you, I want to segue into this concept of psychological safety. And one of the phrases that I love that I've heard you use in our work together is this concept of a fearless ICU. And I think it's a powerful term. If you could describe what you think that means in just three words, what would they be and why would they be that?

Sergio:

Well, that's a great question and a hard one. Yeah. But if I had to choose three words, I would say curious, safe, And accountable. Curious because I really believe that a fearless ICU is all about learning. Learning how to do things better, but also learning from our mistakes. It is impossible to deliver complex care to critically ill patients on a daily basis and not make mistakes.

Ashley:

Right.

Sergio:

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 opportunity and we can talk about it. So that leads me to the second word, which is safe. I feel safe to not only take risks as a leader or as a nurse or as a physical therapist and giving my opinion, but I also feel safe in bringing up problems to the team and to not be criticized, ostracized, or demeaned but to be thanked for bringing up a problem that we can all work on together to move in the right direction. So that's the safety part, which ultimately also plays into another safety area, which is patient safety. If teams can't talk about mistakes, it's very difficult to provide safe care. And finally, I said accountability. And this is important because when clinicians, especially in the ICU, which is a high stakes, high adrenaline environment here, psychological safety, they immediately go to like a, oh, it's a kumbaya thing and like a soft thing. And it's not about that. We still want to be accountable to each other. And what we're looking for is the highest performance. But it's come to the realization that without us having that learning experience, growth mentality without making it safe and inclusive for everybody, we cannot perform at the highest level, period. We just can't. So accountability is important. The goal is to perform at the highest level. These are very sick patients and things we decide can really make the difference between surviving and not surviving. Sometimes there is no chance for surviving, but we still want to perform at a high level and making sure that we can take the family through that process in the most compassionate way. So I think that going back to the three words, it would be curious, safe, and accountable.

Ashley:

Right, right. I love that you added the accountability because you're absolutely right. In leaders that I've worked with, one of the biggest misconceptions I hear is, about this concept of psychological safety is that they think it's somehow going to be coddling people. It's going to be too easy on people. You know what, we're going to just, you know, be soft and give them everything they want. They don't realize that that's exactly the opposite of what we're talking about. We're talking about maintaining those high performance standards, but making an environment where that can actually function. Yeah. Yeah. Why do you think it's so critical in clinical environments that this exists?

Sergio:

Critical care is probably a magnified example of healthcare. But if you took healthcare as a whole, the reality is that it's a complex environment with high stakes. And as a complex environment, we know parts of what we need to do, but we don't always know everything we need to do. It's not like if you're baking banana bread, there's 10 steps, exact proportions. And if you do that, you're okay. In critical care, you might do the first 10 steps right, and the outcome might still be a negative one. So it's a complex environment. As such, you're constantly trying to learn, but you also have a lot of moving parts. And if those parts don't feel safe to interact, to show up in their best version, to give their 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. It's impossible to deliver high-level care consistent. And it's very interesting that in medicine, we are taught that failure is bad. Now, there are different types of failure. Some of them should absolutely be avoided 100% of the time. Like if you go to surgery for a right leg amputation and they amputate the left leg, well, that's a Never event. That's a problem, right? However, there are situations in where we might fail in saving a patient, but everything was done right. So how do we learn from that? And the ability to learn from failure is embedded or based on psychological safety. Can we talk about what we did wrong or what we could do better in a safe way where everybody can learn? And that is the most important factor to provide safe care, but also ensuring to keep evolving. We have situations like COVID where we have no idea what to do. Well, if you're not in a psychological safe ICU, how are you going to learn as quickly as you need to provide that care to those patients? And running several ICUs through our practice, I saw that. I saw some ICUs did better than others. with the same amount of information, the same level of ignorance, right? But some ICUs were safer from a psychological standpoint, and they worked as a team to figure things out. And others were paralyzed by the fear of failure, by the fear of communicating. And ultimately, the patients are the ones who have to pay that price.

Ashley:

You had Dr. Amy Edmondson on your podcast twice. And Amy Edmondson is, of course, the person who came up with the concept of psychological safety through her research and her work over the years. And I'm curious, because your podcast is really focused on clinical care medicine, and your listeners are clinical care physicians for the most part, what drove you to bring her on? And why did you think that her work was so important for your listeners to understand?

Sergio:

That's a great question. And I would say that The reason why I brought her on is the reason why she probably accepted to do it. Amy Edmondson, as you mentioned, is a professor at the Harvard Business School. She has done amazing research in the area of work environments, complex work environments and performance and coined the term psychological safety. She has studied ICU teams throughout her career. in terms of identifying what are the factors that make one team perform at a high level versus a team not perform so well. And she's identified that the most important factor is psychological safety. Yet as relevant as her work and her findings are for the practice of critical care medicine, it is not discussed in clinical arenas. Now people are talking about this concept, but when I was a fellow, I didn't even know this word existed.

Ashley:

Yeah.

Sergio:

When I was a young attending, starting a fellowship, it wasn't even on the radar of things that we should teach the fellows. Yet, it's probably the single most important thing in performing at a high level day in and day out. We train critical care physicians to be the leaders in the ICU, but we weren't training them or teaching them about the most important thing they should build in their ICU. We were talking about all these diseases and mechanical ventilators and drugs to raise the blood pressure and diseases like ARDS and septic shock, which is all important. But without psychological safety, it's impossible for a team to perform at their highest potential. And that is what we all want when we show up to work. So that was the reason why I thought it was important for her to come and share her message and her insights and what she learned through years of research. And I believe that that's why she also thought it was important to talk to a very clinical audience because she recognizes that it's almost like parallel worlds.

Ashley:

Yeah.

Sergio:

And we need to connect a little bit more.

Ashley:

Yeah. Yeah. Did you get any feedback from your peers on those conversations?

Sergio:

I did. And when you do a podcast or when you give a lecture or write something, you want it to have the maximal quality. But the reality is that as long as a couple of people take it to heart and they do something to change what they're doing, it's a win. And I actually know some ICU directors and fellowship directors who really embraced the concept and was like an aha moment. We should be teaching this to our team. We should be talking about this. One of my friends who I had trained and now is the head of critical care at a large university program bought Amy Edmondson's book for the whole team and they started reading it. So I do believe that it resonates with a lot of people.

Ashley:

Yeah.

Sergio:

And what I found also, Ashley, is that I have done a lot of talks around the world, actually, about the fearless ICU.

Ashley:

Yeah.

Sergio:

And I've talked about this in the United States and different settings. I've talked about it in the Middle East, South America, in Mexico, in Europe. And what I find is that when people hear the talk and the concepts, they immediately recognize something they live every day. Yeah. But all of a sudden they have a language that Amy Edmondson has created to articulate it, to explain it. And it's like, Yes. This makes perfect sense. Right. Right. Thank you for sharing this. So I definitely think that it resonates with clinicians because everybody who's a critical care clinician has seen what psychological unsafe teams look like. Yeah. Yeah. Some have seen what good looks like, but everybody has seen what bad looks like. And they can say, yes, I see that. It resonates. Now I know there are things I can do to change it.

Ashley:

Yeah, yeah. Sometimes it's so much easier just to be able to identify the things you don't want before you can really shape what you do want. Well, let's talk about mindset because a lot of this is about that, right? That shift of mindset because we know that most clinicians are trained to lead with authority, with certainty, with expertise, even perfection if we go down that road. But this takes a little bit of a shift. So how do you help your clinical leaders shift their mindset and lean a little bit more into some of the behaviors that psychological safety requires, like being a little more vulnerable, being a little more open? How do you do that?

Sergio:

Yeah. Well, the best way to shift people's mindset is to ask questions and asking questions that lead them to the answer you want. I think that's a great way to start. But also a lot of times it's just showing them or exemplifying the behavior, obviously, but also pointing out to our leaders or to our colleagues examples of why psychologically unsafe behaviors are detrimental to our patients and to our team. And it's a little bit of a combination of asking questions, role modeling, and giving the people feedback of, the damage that bad behavior does in that respect.

Ashley:

Right, right. Yeah, that makes sense.

Sergio:

And talking about it, obviously. We talked about the Furious ICU in our leadership meetings. We talk about it in clinical settings and fellowships now. So also, the first step is to identifying we have a problem and talking about it and trying to provide some solutions. And again, some people embrace it, but not everybody. That's okay, as long as we're moving the needle.

Ashley:

That's right. That's right. Critical mass. All right. Is there a moment that you can share that you've actually seen a team have a breakthrough in psychological safety and what made that possible in that example?

Sergio:

So as a breakthrough, I would say that studies have shown, and a lot of these studies, again, come from Amy Edmondson's team, that the quality in a leader that most likely correlates to psychological safety is being inclusive.

Ashley:

Okay, yeah.

Sergio:

So breakthroughs I've seen in clinical care when they're rounding and the new nurse doesn't really speak up during rounds. And the intensivist who's leading the rounds might say something like, Ashley, I know you're new to the team. You've been very quiet during this patient's presentation, but you are helping care for this patient. I really want to hear your opinion. It's important for us. What do you think we should be doing? Or is there something that we should know? And it gives them permission to contribute. And I think, especially in medicine, which is very hierarchical sometimes, that's hard for new people. A similar breakthrough might be in a team meeting among physicians. When there's one physician who's very quiet about a new change that you're trying to implement to the ICU. And again, you might say, Sergio, You've been very quiet. I can't read if you're in agreement or disagreement, but either way, your opinion matters. Could you share what you're thinking with us? Bring them in, invite them to talk with you. That is the best way I believe to break through. The other breakthrough that I've seen in different settings is how a leader handles bad news, right? Do we shoot the messenger?

Ashley:

Right. Exactly.

Sergio:

And then obviously people are going to say, well, I'm not talking next time. Or do we acknowledge the problem and thank the messenger for bringing it up to the team?

Ashley:

Right.

Sergio:

When they question something you are doing as a leader, obviously your initial reaction 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 of creating a small breakthrough with psychological safety.

Ashley:

Isn't that what Amy Edmondson calls responding productively, right? When somebody does take a risk and come to you with something, the way that you respond matters. Absolutely. You know, the other thing that pops into my mind is we've talked in the past about people's experience of psychological safety is different. And there are different factors that attribute to that. And just being aware of that fact, whether it be hierarchy, whether it be are they non-native English speakers, gender, all kinds of things that can get in the way where we might assume their psychological safety, their experience of it might be different.

Sergio:

Absolutely. And again, there are studies in medicine. about this and on average physicians are going to feel safer in the ICU than nurses who on average feel safer than the respiratory therapists and it might have to do with perceived roles with number of people with years of experience it was a lot of of issues but you're right and we have to acknowledge that as a executive physician who's a middle-aged white male I have a lot of privilege and I feel very safe, but I don't have to assume that everybody on my team feels the same thing I feel.

Ashley:

Right.

Sergio:

Right. And being able to recognize that is important. And the way you slowly move that needle is by making sure that everybody is included and feel they belong to the

Ashley:

team. Right. Exactly. Well, let me ask you this. We were talking a minute ago about the data that supports this. And I think that's a really important point because too many people might have the misconception that this is a soft science. But this is not just a soft science, right? There's more and more studies that have been done in healthcare that demonstrate the impacts to really measurable outcomes, right? Safety, quality, team performance, morale, retention, all those factors. What measurable impacts have you seen in your experience on those kinds of outcomes when psychological safety is prioritized in a team?

Sergio:

Well, I think that one of the things that is very evident is the number of safety reports that a team will submit. If you have two ICUs and one reports on average, let's say six to seven patient safety events every month, and the other ICU reports zero, your first thought is that I want to be in the second ICU because it's safer. My thought, based on the data, would be I want to be in the first ICU because in both ICUs there's problems, but only the first ICU talks about them.

Ashley:

That's right.

Sergio:

And I always say with patient safety, the ultimate measure of clinicians feeling safe is when they self-report patient safety events, which is very hard, right? When they self-report, can we review this case I was involved with? I think I may have made a mistake. That is the ultimate measurement of psychological safety, and it's hard to achieve. But also, there are very good studies outside of medicine. Google did a massive study where they looked at what were the determinants of high-performing teams, and this is performance-measured by dollar signs, right? Which teams deliver the highest return, the highest product, and the single most important factor by far was psychological safety. Does the team members feel safe to ask questions, to interact, to show up at their best version, to take small risk? So it's there, you can see it in different outcomes for sure.

Ashley:

Well, let's make it really clear. If you're on that team in the ICU that maybe doesn't have as great a psychological safety as the other one, what do you think signals to people that it's not safe to speak up? What kinds of things would be happening?

Sergio:

Part of it might be learned behavior from previous jobs. A lot of times, new members and teams in health care constantly change, not only over time, but on a daily basis, this concept of teaming, right? People show up as a different team every day in some respects. So they might have learned behaviors from other teams, which unfortunately is very prevalent in healthcare that we have psychological unsafe teams. And maybe they saw somebody else get into trouble for bringing up a problem, so they don't want to bring it up. Or they presence that somebody asked a question and got reamed or got demeaned or got ridiculized for not knowing something. Or there was a difficult patient interaction and the way the people involved reacted was very negative. So these are all things that would push me as an individual to not take that risk. I don't want to be seen as incompetent. So I'm not going to ask if I don't know. I don't want to be seen as disruptive. So I'm not going to say, well, maybe we should do this different. I don't want to be seen as negative. So I'm not going to say we have a problem. And these are just normal human behaviors that we all have. But if we are in a business that's here just taking care of critically ill patients, you got to put what's best for the patient first.

Ashley:

Yeah. And what's the cost of that silence in your mind? What is the cost?

Sergio:

It's death. Death for the patient. Death for other people. When you mentioned the cost of silence, there's a lot of case studies about NASA and the Space Shuttle Challenger, I think it was, or Columbia. I don't remember which one. That obviously exploded on the way back and one on the way up and one on the way back and killed seven astronauts.

Ashley:

Yeah.

Sergio:

When they actually investigated what had happened,

Ashley:

What

Sergio:

they found was that there was a pervasive, unsafe psychological environment in NASA and that people who knew that there was a problem did not feel empowered or did not feel capable of speaking up to the right person. So it leads to death. We see it in medicine. There are famous cases of wrong side surgery, giving somebody a medication that they're allergic to. Now, there's a lot of safeguards in place for that now with checklists and all that, but every time they reviewed one of these seminal cases, there were people involved in the care that thought something was wrong, but didn't feel safe to speak up. Right. So the consequence is death.

Ashley:

Yeah. Yeah. Truly. Yeah.

Sergio:

Truly death. Yeah.

Ashley:

Wow. Wow. Well, what is your way to look at a team if you're going out and gauge where they're at in their level of psychological safety? What kinds of or signals or behaviors helps you see where they are. Yeah.

Sergio:

So one of the things that you can observe very quickly is how people contribute to the conversation. If there are some team members that 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 you don't know. Everybody knows something that somebody else doesn't know. So when you're trying to work as a team, you have to have, you always have something to contribute.

Ashley:

Right.

Sergio:

No matter what the role is. So when you see silence on a repeated basis or when you see a team get bad news and there's no response. Right. Okay. You wonder, is it really nobody has any questions? We just changed the way we run our call schedule and there's no questions. Yeah. Right. No, this is an unsafe team. And then also, obviously, when teams have a death or a difficult clinical situation or a mistake or a problem, how they react, that can be very telling in terms of the level of psychological safety that there is. A low level would be somebody being berated during a resuscitation for not doing something fast enough. you got to take care of the patient, but that's not the time to berate somebody or how people respond to questions. Like something along the lines, you should know that is not psychological safe.

Ashley:

Right.

Sergio:

Right. Our job is to make sure that they, that they learn it.

Ashley:

Right.

Sergio:

And if somebody asks a question, they should be applauded for asking the question.

Ashley:

Right.

Sergio:

Because they're wanting to do their job better. And if they don't know, they should ask. Right.

Ashley:

Yeah.

Sergio:

Um, In terms of psychological safety also, if somebody can point out that somebody's about to do something that might be dangerous in a productive way, how that person responds, if they're defensive versus you're right, thanks for pointing that out for me, that's a psychological safe environment. And what I would also say that it's no different in families and and relationships. It's true. You might not get a good picture just on a brief interaction. Right? We all know perfect couples who then totally, right, become among our friends and you don't know the tip of the iceberg that you see. So you have to be a little bit more embedded in the team to really appreciate how the team functions.

Ashley:

Right.

Sergio:

So a lot of my experience insights into where teams are safe or unsafe might be talking in more depth with members. But just from observing them sometimes, you don't always tell. True. But like I mentioned, when you see those telltales, okay, you say this is probably a team that is safe. This is probably a team that is not as safe as they should

Ashley:

be. Yeah, there are clues. There are clues. I agree. For sure. And I think this is a major problem. And unfortunately, I think too often the aspect of unsafe teams are what we're seeing more. We're trying to turn the tide. We're trying to get that language out there, that awareness. What do you think are some of the biggest cultural or systemic barriers to this that you see in either the ICU setting or any clinical setting?

Sergio:

I'll answer that question through the lens of the ICU because that's what I know and what I believe. I would say that one of the big barriers is What we've learned before.

Ashley:

Yeah.

Sergio:

Right. It's almost like it's generational trauma that keeps going forward. Right. Yeah. We grew up in a medicine has always been about not making mistakes.

Ashley:

Right.

Sergio:

And the idea of the superhero. Yeah.

Ashley:

Yeah.

Sergio:

Superheroes are not usually vulnerable, right?

Ashley:

Right.

Sergio:

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 the answer is always, I will do better next time.

Ashley:

Right.

Sergio:

So you're taking the blame. Right. So you bring that baggage with you. So that's the first big problem. Second barrier is I don't believe that most clinicians have the framework and language to talk about this and to move the needle productively. These are skills, right? It's not like leaders are, we talk about this all the time. They're not born. It's not like, okay, this is an inclusive leader from birth. And this is a leader who just creates chaos everywhere they go from birth, right? No, these are learned behaviors. And to learn them as a skill, you have to have the language, the framework, and you have to talk about it. which again, I mean, if you were to look at critical care training programs, probably 10 years ago, I would say zero talked about this topic. Now, I would say it's a small percent, but the majority of trainees get to the ICU without any real discussion about these topics. The last barrier I would say is that We always make the analogy of the ICU team as being a sports team, right? Or we're high-performing, depending, I mean, which sport you like and which era you grew up. I trained in Chicago in the Michael Jordan era, so you would talk about the Bulls as the ultimate team, right? The reality is that we don't have that in the ICU because every day I show up to the ICU, it's different people. Some people I'm more familiar with, but some people I might be meeting for the first time. And you have to create a psychologically safe environment all the time, every day, right? Get to connect with people who you don't know very well in a safe manner. And that's a barrier, but it's something we need to learn because that's just the reality of healthcare.

Ashley:

Yeah, yeah. One thing I thought about when you were talking too about how this is a skill, right? This is something you can develop. I think it is about learning as much as it is about unlearning. old behaviors, old ways of thinking, old entrenched anxieties and that baggage that we bring into it, then that's hard sometimes. But at least acknowledging that those things have existed, I think is really important.

Sergio:

Absolutely.

Ashley:

To then be able to take that next step.

Sergio:

Yep. We have to outgrow old models of leadership, old models of performance, old models of teamwork, for sure.

Ashley:

Yeah, yeah. Well, you, I think, are really in a unique position because you're a practicing physician, but you're also a chief medical officer, right? And that bears a whole different sort of responsibility. So as that level of leader, what specific actions do you feel that leaders within your care need to take to create and sustain a psychologically safe culture in their groups?

Sergio:

You know, Ashley, from working with me that I like three, so I'll give you three. where you are in your journey or where you are within your organization, whether you hold a title or not, these three behaviors can help promote psychological safety for a team. Number one is to frame the work appropriately. What do I mean by that? When we were taking care of COVID patients, we had to acknowledge that, yes, this might be dangerous for us. Yes, we have no idea. where this is the right thing or 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 very clear deliverables that are expectations, say that to the team very clearly. This is what we expect. This is what for today. This is the goal. This is what I expect from the team members. This is how we can make this happen. So frame the work. very, very accurately in terms of what's expected, but also what's unknown or what might be problematic. Number two is respond appropriately, like you said, and you talked about Amy Edmondson emphasizing this. What do I mean by that? If somebody does something good, recognize that in public, right? If somebody does something good, that does not conform with the norms of the team, talk to that person in private, but immediately. If somebody asks a question, answer the question without demeaning the person. If somebody brings up a problem, acknowledge the problem, thank the person for bringing it up, and then take care of it. How we respond to bad apples sends a big message. If we have a team member that is constantly demeaning others, being unprofessional, and we allow that to go on and go on and go on, the team's not going to feel safe. And eventually other people are going to assume that's allowed and they might do it as well. So responding appropriately to good behavior, to bad behavior, to bad news, to good news is super important. And it always sends the signal, right, to others. And finally, the third is about being inclusive, which really means inviting people to participate. Constantly inviting people to participate, but also valuing what they have. Now, if I'm in charge of making a decision, I can invite to give me your opinion. It doesn't mean that I have to do what you say, but if I acknowledge your position or your opinion as a valid one and we take it into consideration,

Ashley:

I'm

Sergio:

including you in the conversation. And then you will feel that you belong to the team because eventually they will follow your opinion, right? So I think those three things, framing the work appropriately, responding productively, and inviting people to participate are three things that we can all do, right, on a regular basis to move the needle there.

Ashley:

Yeah, yeah. And I think on that last point about Listening to people's points of view, I think a second part to that was once you've taken in their point of view and you validate it, there's follow-up. There's a loop there that I think sometimes is whether or not anything happened from what they wanted to say, but just recognizing and following up with them so that they understand that something was actually done with it, I think can be also very much a part of that.

Sergio:

Absolutely.

Ashley:

Yeah, yeah. I think that's great. Now let's get tactical. You've got one leader in front of you, maybe a newer leader. or somebody who really wants to start doing this today, start doing it well, what's the first thing that you think they should do? Where should they begin?

Sergio:

Inviting the people who don't talk to share their opinion.

Ashley:

Yeah. Why do you think that one in particular?

Sergio:

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 the most common things we do in the ICU is we do clinical rounds. So the day usually starts, you get there, you get signed off when the person was there before you. At night, let's say, you kind of start seeing patients and then at a given time, depending on the ICU, eight, nine, it already gets together at one of the beds and we start talking about each patient. So there's a group of people that are talking about the patient. And if somebody's not sharing that you might not have time to every single time have everybody one's opinion. But if you notice that somebody is very silent, asking them for an opinion and telling them that your opinion is important and valuable, signals to the team safety. So that's the first thing I would do. The same example would be in a team meeting with colleagues. As you know, and you worked with us for many years, collaborated with Sound, we have multiple practices around the country. And usually the team of clinicians that includes physicians, APP, CRNAs, and in some instances, nurses might have a team meeting. And maybe the director, the program director is sharing a new demand from the hospital, something the hospital wants us to do, which you immediately think is a new brick on their backpack.

Ashley:

And

Sergio:

now they want us to do this, right? Everybody's rolling their eyes, but nobody says anything. Or everybody talks and then somebody's silent.

Ashley:

Yeah.

Sergio:

You know that they're not feeling safe to share or they feel that they share it's a waste of time. Now, we might not be able to change 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 that maybe they're looking at through the wrong lens. So that's another example. Invite them to participate. 20 members not talking at all. Joe, I noticed you're very silent. We really value your opinion. Could you share with us what you're thinking? And it's possible that Joe doesn't say anything that time, but you make that note and next time.

Ashley:

Yeah.

Sergio:

You ask them. And if you're running a meeting with a small number of people, you should be checking, right, who's talking and who's not talking.

Ashley:

Right.

Sergio:

There's a fascinating study from the MIT group many years ago that looked at the performance of teams. And these were smaller teams, like three to five people working on creative tasks. And what they found is that Equal speaking time

Ashley:

was

Sergio:

one of the most important factors, right? And it speaks to psychological safety. Everybody felt safe to give their opinion. So when you have more angles at it, you can find more creative solutions.

Ashley:

100%. And what I was thinking about, and it's so great that you brought that up, is I think a lot of leaders, especially young leaders, feel the need to talk a lot. Right. They're driving the meeting. They've got to be the ones out in front. And there is power in maybe setting it up, but then stepping back and letting the others talk. And that's, I think, a perfect example of

Sergio:

that. Absolutely. Absolutely.

Ashley:

All right. Well, I've got a couple more things for you before I cut you loose, Sergio. So I want to think about you. If you were to look back, look at yourself 20 years ago. What's something that you would say to yourself or something you wish that you would have learned earlier in your career that maybe you You couldn't use back then.

Sergio:

It's funny that that question comes now because you just mentioned me as a young leader.

Ashley:

Okay.

Sergio:

I would say listen more, talk less. Yeah. And about listening, what I would say is listen with the intent of learning.

Ashley:

Right.

Sergio:

And I look at some of my first leadership, quote unquote, leadership meetings.

Ashley:

Right.

Sergio:

Which I thought I had. nailed it then I realized all I did was talk yeah what a failure right and I still everybody likes to talk and you know me I like to share ideas and talk but I would say that talk less listen more yeah is the most important lesson I would teach my younger self yeah because it makes such a difference right

Ashley:

yeah yeah well absolutely I love that All right, so last thing I want to do with you, if you're down for it, if you're game, I'm going to ask you my quick set of questions I like to ask people at the end. How do you feel? Are you good? We're ready? Okay. So the first one is, what's one word to describe your leadership style?

Sergio:

Curious.

Ashley:

I like that. What is a leadership value that you won't compromise on?

Sergio:

Kindness.

Ashley:

Yeah, that makes sense. What's the most important habit you've built as a leader?

Sergio:

Ah,

Ashley:

okay. Why that?

Sergio:

Because it's like networks. There's strong ties and weak ties. And when you read a lot of different topics, it's almost like you have a big network of weak ties that all of a sudden give you answers or show you paths. That if you just read medicine, you would have never found. Right. So I think that expanding your brain by reading a lot and different things can really help you in your day-to-day work.

Ashley:

Love it. Love it. All right. So what is one thing that helps you reset after a tough day?

Sergio:

My dogs.

Ashley:

Nice. What was it? but my

Sergio:

kids are all gone and my granddaughter is in New York but yeah my family my dog my pets I think especially the dogs because they're with me right now and they're I wish that we all behave like them they're so noble right and They always seem to be living in the moment.

Ashley:

They do.

Sergio:

Which I believe is very resetting for me.

Ashley:

Yeah. All right. What is something you used to believe about leadership that you no longer do?

Sergio:

That you have to be the smartest person in the room to lead.

Ashley:

Yeah, for sure. What is the biggest lesson that you've learned from your team? One

Sergio:

of the things I've learned from my team that has been very humbling is that Don't assume that what you value is what other people value.

Ashley:

Yeah, yeah.

Sergio:

And I think it's true for patients too.

Ashley:

Agreed. That's a good one. What's your favorite question to ask in a one-on-one?

Sergio:

About books. The book that has influenced you the most or what book have you read lately? And that's very, I want to learn, but also I'm looking for more things to read. Love it.

Ashley:

Love it. Well, on that topic, what's a book or resource that you think every physician leader should know about? I

Sergio:

have found that Meditations by Marcos Aurelius is a phenomenal read and I read it over and over again. Really? And what it's taught me is that if the most powerful person on earth at that time

Ashley:

was

Sergio:

so humble and really thought of leadership as a call to serve others, who am I to argue? And it's a great example of how to really Lead by trying to improve yourself, but also by recognizing that the value in leadership is not in what you achieve, but in what you achieve for others.

Ashley:

Yeah. All right. Last one. One thing every physician leader should try this week.

Sergio:

To include, invite somebody to participate in a meeting or in a clinical rounds or in a patient discussion.

Ashley:

Love it. Love it. Well, Sergio, thank you so much. I've so appreciated you being here. I appreciate your thoughts, your wisdom, your candor. Always appreciate it. And

Sergio:

as

Ashley:

a leader and as a human. The

Sergio:

same here. And I appreciate having the opportunity to talk with your audience and on your podcast and also... Appreciate the opportunity that we've had over the last couple of years to partner together and teaching, but really in learning together, which is ultimately the most important thing.

Ashley:

Agreed. Agreed. My thought is you are such a delight to work with. You really are, Sergio. I appreciate that so much. I love sharing that teaching spotlight with you and agreed. I've learned so much from you. So I hope you come back. I know we can find other things to talk about. I love your insights and your thoughts. So thank you so much.

Sergio:

Thank you.

Ashley:

All right. Take care. For everyone listening, I hope you found this conversation with Dr. Zanotti as thought-provoking as I did. His perspective on curiosity and the quiet signals of psychological safety in teams really underscores how leadership is less about knowing all the answers and more about creating the conditions where others can speak up and show up and grow. So if you're a clinician leader wondering where to start, remember Serge's advice. Invite somebody into the conversation, especially the quiet ones. Psychological safety starts with those small, intentional acts of inclusion. Thanks, everybody, for listening. And if you found value in today's episode, please consider sharing it with a colleague or leaving a review. And if you're not already subscribed, hit that follow button so you don't miss future episodes. Thanks for being here. Take care, and I'll see you next time.

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Ashley Wendel, MA

Host