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Cardiologist Lauren Weber and critical care physician Jess Bunin, co-founders of All Levels Leadership, discuss their article, “Not all heroes wear capes: Sometimes they just speak up in meetings.” They reframe medical heroism, arguing that the most courageous acts often happen not in a code blue, but in a conference room. Lauren and Jess define this as moral courage: the quiet bravery to question a dismissive attending, flag an unsafe policy, or challenge the status quo, even within the rigid hierarchy of medicine. Drawing on the work of thinkers like Ira Chaleff, they explore the role of the “courageous follower” and assert that true professionalism includes speaking up, not staying silent. The conversation makes the case that these small, uncomfortable acts of integrity create a “courageous contagion,” empowering colleagues and building safer systems one conversation at a time, and that these everyday heroes deserve our full support and solidarity.

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Transcript

Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast. Today we welcome Lauren Weber and Jess Bunin. Lauren is a cardiologist, and Jess is a critical care physician. They’re co-founders of All Levels Leadership. Today’s KevinMD article is “Not all heroes wear capes: Sometimes they just speak up in meetings.” Lauren and Jess, welcome to the show.

Lauren Weber: Thanks so much for having us.

Kevin Pho: All right, so I’ll just ask you to briefly share your stories, and we’ll jump straight into your KevinMD article. So, Lauren, why don’t you go first?

Lauren Weber: As you mentioned, I’m a clinical cardiologist. Before that, I trained at the Uniformed Services University and really did all of my training and early career in the Navy. Until a couple of years ago, I had completed my military service and I really, in addition to transitioning out of the Navy, also transitioned out of academic medicine into more group practice. And I found that there were some gaps in my professional career that I had really missed. One is a real passion for teaching and developing people, specifically in how to be influential as leaders, regardless of the role that they’re in. So that led me to co-found All Levels Leadership with Jess.

Kevin Pho: All right, Jess, briefly share your story and then talk about what led you to write this article on KevinMD with Lauren.

Jess Bunin: In a past life, I was a psychiatrist, but as you mentioned, I’m now an intensivist. My passion for leadership started with my college education. I went to the United States Military Academy at West Point, where I learned a lot that I had never heard about, even at that time, but then started a career in the military. I did 23 years in the military and for the past six years, have been in academic leadership and have had the opportunity to do a lot of coaching, mentoring, and teaching about various leadership practices.

And as I transitioned out of the military, it struck me as being so important to find a way to keep teaching this material to generations of physicians still to come, which I think is really undervalued and undertaught in our institutions. And so, again, that brought us around to this idea of All Levels Leadership and to this idea specifically of moral courage, which is what we’re going to talk about today.

So, back in 2017, Lauren and I did a talk on followership at a national conference. After that talk, we had a line of folks who wanted to ask questions to us afterwards. And what we found was we had talked about numerous different courages of followership during the talk, but people really zoned in on this idea of how can we work on this one specific courage, which is the courage to practice moral action. We found that that was what people were craving and didn’t know the language for and didn’t know how to practice. So we went back and dived into the literature, doing a lot of reading of books to try to find the best way to teach this material, as well as to practice this material in our day-to-day lives and in our leadership practices. And I’ll hand it over to Lauren to talk a little bit more about that.

Lauren Weber: I think as we were getting started, there were a couple of things that we recognized, which was that, as Jess mentioned, there’s a lot of day-to-day stuff that’s going on in the background that requires moral courage.

We were really trying to figure out how do we get our arms around this to practice it? How do we give people tools and techniques? That’s a lot of what we are trying to do: give people tools to manage the things that are affecting their lives. So we needed first to find a working definition of moral courage.

And we did that really when we found Rushworth Kidder’s book Moral Courage. He defines it as a state of mind or spirit to be able to step up to ethical dilemmas without flinching or retreating. It’s not exactly that, but that’s kind of the intent. And every time I read it, it sort of makes me smile because I think embedded in the definition is this sense of, this is going to be hard.

Kevin Pho: So Lauren, what would be a scenario where moral courage would come into play, say, in a clinical setting, just to kind of illustrate that?

Lauren Weber: It’s a great question. I think we stumble on so many problems and dilemmas in our day-to-day lives, and not all of them require moral courage. And so it’s helpful to have a framework to kind of cue into, is this a moral courage situation? Jess likes to say that “flinch” part actually may be your first clue.

To me, you really need three things: There has to be a value at stake, so a value or principle should be in conflict. There usually needs to be a danger, meaning if you are going to step up to protect this belief or value, there’s some potential consequence. Maybe that’s a loss of reputation. Maybe it’s a loss of friendship or relationship. And in big-stakes situations, sometimes it’s a loss of employment. So these can be big, big things that are at stake. And then the last one, which is the hardest part, is the ability to endure the dangers for the sake of the belief.

I think this comes up a lot for patient safety. This is probably the most common venue where we have to talk about aspects where we’re going to need moral courage. And we know even in that setting, this can be really hard to do.

Jess Bunin: To dive into the specifics of this a little bit, studies have been done with thousands of residents and asked them when they are willing to challenge people in a patient safety scenario. We found that even when there’s a high risk for patient harm, only about 20 percent of residents are willing to challenge their attending and say, “Something’s about to happen to our patient here; what can we do about it?” But then if there’s a professionalism element, if their attending is disrespectful, if their attending has been difficult to work with in past scenarios, that number goes down to 9 percent. Only 9 percent of residents are willing to challenge.

So we feel that if we can start with small scenarios, like seeing someone be disrespectful to a peer in the workplace, and learn the tools and the language to be able to challenge in these small scenarios where the risk isn’t huge, it’s not a high-stakes environment, and there’s not a lot that you’ll need to endure. It’s a peer relationship; you’ll recover. But flexing that muscle so that when it does come to big, life-changing situations, it comes naturally.

So we think about two specific models that we can use to help folks learn this. One is the two-challenge model, which actually comes from TeamSTEPPS, which is you hear something inappropriate has happened, you’re obligated to challenge with that moral courage once. See how it goes. If it doesn’t change the course of the action, you still have to challenge again. And if there’s still no effect, now you need to find allies or find a different way to alter the situation. But taking two challenges in and of yourself is a big part of it.

The second tool we think of is using something called the DESC model, where D is to describe the actual action or words that were used that were problematic or offensive, E is to explain how you heard them using “I” statements and why that matters to you, S is to suggest how a more effective way to handle the situation might be, and that final C is to think about what are going to be the consequences: for the patient, for the relationship, for the leadership scenario, whatever it might be. What are those consequences, and how can we overcome those consequences? So having that model of thinking about what did I see? Why did it matter? What else could we try? And what’s going to go wrong if we don’t change course?

Kevin Pho: So Jess, what would be an example, let’s say, of the two-challenge model? Say, in a typical clinical scenario or a scenario that happens in a medical institution or a hospital, what can that look like?

Jess Bunin: That could look like you’re on rounds and a senior resident is leading a team, you’re doing multidisciplinary rounds, and a nurse is on rounds. The intern is talking and says something disrespectful to the nurse or just disregards a recommendation or a report of information from the nurse. Another intern on the team could say, “I’m not sure we took time to hear what the nurse had to say. Can we stop and do that?” And then if the intern barrels right through and keeps moving forward anyway, say, “No, I’m still not sure I heard what nurse so-and-so had to say.” And then if their peer is still not willing to shift course, maybe look to the resident for a little more support there, or turn directly to the nurse and say, “Wait, stop. Let’s hear your full point. Let’s hear the story of what the patient told you that maybe he didn’t tell us, even if that information contradicts.” So that would be a simple scenario of how that might occur in a low-stakes situation among a peer group that will likely even be forgotten about by the time rounds is over, but it gave them an opportunity to practice that in real time.

Kevin Pho: Lauren, why is it so difficult for clinicians, across the health care spectrum, to really speak up? Like you said, when you guys gave this talk, it was speaking up and flexing that moral courage that was very difficult for a lot of physicians. Why is it so difficult?

Lauren Weber: That’s the question, right? Why is it so difficult? I think there’s a lot of things that go into that. Medicine’s a hierarchical structure, by and large. We have a lot of deference to seniority and expertise, and those things definitely play a role. I think people are worried about how their peers are going to view them. They worry about the consequences.

And then I think there’s also just a sense of, somebody else is going to take responsibility for this; I don’t have to take responsibility for this. We have sort of seen this happen where cultures have really been affected by this wave of silence that is going on, where everybody is kind of quietly just hoping that somebody else is going to say something. And that gets back to the article where we say you don’t have to make big gestures. Often it’s these little actions of courage.

I think having a framework, which is one of the things we’re trying to provide people, gives them even the courage to start to use it. You can speak up at a meeting; you could speak up in a hallway. If you see something that’s giving you that sort of “ick” feeling, like I have a value here, I have a belief that’s in conflict.

Kevin Pho: So Lauren, through your coaching with Jess at All Levels Leadership, give us an example of how this framework can help overcome some of the hesitation physicians may have in terms of speaking up and exhibiting some of that moral courage.

Lauren Weber: That’s a great question. I think the biggest thing is that this is doable. You can learn how to do this. And so we, of course, review the techniques, but then the other thing that we try to help people build is what we call a moral courage support system. That’s a combination of trusted advisors, peer networks, and potentially knowledge sources that you need. And the last one is what’s going to help you endure, so what are your wellness techniques that keep you moving forward in these scenarios?

Jess Bunin: Absolutely. And so, some of what Lauren already mentioned is this: How do you practice these? You practice these with the peer network and the trusted advisors. I like to say find a “moral courage survivor,” and that has definitely come out in the workshops that we’ve given. We find people and have really been privileged to hear some very vulnerable stories of how people have spoken up. Sometimes they’ve managed to change things. Sometimes that means that they’ve had to step down from a position or even leave their job altogether. But those folks are a wealth of information. They help our endurance.

We also talk about what Lauren said, which is sometimes it does get to the point where walking away is the right answer. If you feel like something is truly against your ethical code and it’s not going to change in the environment you’re in, or something is affecting your wellbeing, your health, or your job progression, maybe walking away is the right answer.

And then you can use those trusted advisors in that moral courage support system to say, “What other opportunities do you think are available to me out there? What other training should I look at? What other institutions may fit with my moral code more effectively? And how can you help me? How can you sponsor me to get me to that next point?”

And so I think the opportunity to say, “I have a plan in place and I’m going to challenge one more time, but I can go with that alternate plan if things truly aren’t going to change and it’s going to have negative consequences on me for the long term.” We’ve seen it go both ways in our coaching. Sometimes people have grabbed onto that moral courage, challenged someone, and the person has realized, “Wow, I was wrong in that scenario,” and things change. But sometimes folks have said, “No, I’m being too limited in what I’m allowed to do. I’m not allowed to use my voice. I’m not allowed to challenge those around me. I keep getting in trouble for it, and I keep being further limited. It’s time to walk away,” and we can also help people in those scenarios walk away.

Kevin Pho: Jess, for those health care leaders that are listening to this podcast, what are some things that they can do to create a culture where people can have and exhibit moral courage?

Jess Bunin: We like to say moral courage is truly contagious. So just practicing it in front of your team so it doesn’t always have to be something that occurs behind closed doors. It can be something that we do in a respectful manner in public so others can see that we’re doing it.

The other thing I think we talk about a lot is that we expect senior leaders to be the ones who show us this moral courage, and we have to remember that each and every one of us has to do it. We can’t wait for someone else to take moral courage because it may be that their value system is just different and we may never get the results we want if we wait for others to do it.

So getting over the hump to try it yourself is step one. But then when you get good at it and you’ve practiced it, do it in front of others so you can role-model it. And role-model it explicitly: when the scenario is over, ask your learners if they saw that and how might they use that in the future. I think that’s a big part of culture shift: showing what’s acceptable and what’s not. We promote what we permit, and so if we stop people when they’re doing inappropriate things, that becomes the culture.

Kevin Pho: Lauren, in the article you write that these heroes can build safer systems, one awkward conversation at a time. Tell us what you mean by that.

Lauren Weber: We really want to normalize and acknowledge for people that this is hard work. This is hard work. It’s uncomfortable to do. The practice component makes it easier, and I can tell you at this point, I feel like I’m a veteran of having difficult conversations and it’s still difficult for me. I know this, I know these techniques, I know this data, I know the work’s out there, and I still have to go back to my support system and say, “This is the conversation I’m prepping to have,” and then go back after I’ve had it and said, “This is how it went. What do we think?” Because this learning is iterative, and so if you’re feeling like, “Oh, I don’t know, that feels big, this feels like it’s making me nervous,” that’s all OK and, I would say, is very, very normal.

Kevin Pho: We’re talking to Lauren Weber, she’s a cardiologist, and Jess Bunin, a critical care physician. They’re co-founders of All Levels Leadership. Today’s KevinMD article is “Not all heroes wear capes: Sometimes they just speak up in meetings.” Now I’m going to ask each of you just to end with some takeaway messages that you want to share with the KevinMD audience. Lauren, why don’t you go first?

Lauren Weber: My big take-home message is that as I have dived in to learn more about this and then started teaching it, this was something I wish I knew 10 years ago at the beginning of my training. And so if we have the opportunity to sort of spread the word, if I can help decrease the sort of feeling of inertia to just go ahead and learn this as well, that’s what I would like for people to know.

Kevin Pho: And Jess, we’ll end with you, your take-home message.

Jess Bunin: My key point, again, I mentioned this earlier, but moral courage is contagious. When we start practicing it and we open the door for others to do it around us, it gives everyone more strength to do it more effectively. We then start learning the skills each other have and the other ways we may be able to move this forward more effectively for effective culture change. So that’s the biggest point for me: folks can’t do it if they haven’t seen it done, and we have to be the ones to show them how to do it.

Kevin Pho: Lauren and Jess, thank you so much for sharing your perspective and insight. Thanks again for coming on the show.

Lauren Weber: Thank you.

Jess Bunin: Thank you.