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Critical care physician Jess Bunin, co-founder of All Levels Leadership, discusses the article, “Civil discourse as a leadership competency: the case for curiosity in medicine.” They challenge a core tenet of medical culture: the pressure to project certainty and always have the right answer. Jess argues that this fixation on “knowing” makes clinicians fragile and sabotages the ability to navigate difficult conversations on topics like racial equity and systems of power. The solution she proposes is civil discourse, which requires shifting one’s identity from being “correct” to being “curious.” She emphasizes that providing psychological safety is a leader’s primary responsibility in making this shift possible. The conversation provides actionable skills like active listening and perspective-taking, reframing them not as “soft skills” but as essential survival skills for a health care system strained by polarization and burnout.

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Transcript

Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast. Today we welcome back Jess Bunin. She’s a critical care physician and co-founder of All Levels Leadership. She’s the co-author of the KevinMD article, “Civil discourse as a leadership competency: the case for curiosity in medicine.” Jess, welcome back to the show.

Jess Bunin: Thanks so much, Kevin. Thanks for having me.

Kevin Pho: All right, so what’s this latest article about?

Jess Bunin: This latest article is about the importance of us learning to communicate effectively across our differences. I think we’ve done ourselves a great disservice by saying we can’t talk about things like politics or religion. And so instead of getting to know each other, we create barriers between ourselves.

I’ll give you an example of how I got involved in this topic. I was working at an institution where students of two different interest groups were unable to communicate, even in professional contexts. It was one of our religious student groups and our LGBTQ student group, and I was asked to get engaged and involved and solve the problem. Originally, I thought this was a student problem and I was really blaming the students for their contribution to this. But I took it to a staff meeting, and we discussed it at length and we actually said, “No, the problem is us.” We are not doing a very good job of role-modeling civil discourse. We don’t really know what civil discourse is, and so how can we expect our students to be communicating well across differences if we’re not showing them how to do that?

Kevin Pho: I think, of course, you point to a larger problem in society, right? In terms of what you read in the newspapers every day, I think that our society has certainly become more polarized, and we’re losing the ability to communicate with someone we don’t necessarily agree with or someone with whom we have philosophical differences. Now, specifically in a medical setting, why is that a problem? Or how big of a problem is it if we’re not able to engage in civil discourse?

Jess Bunin: It’s a huge problem at every level. It’s a problem for the leadership of our institutions. It’s a problem for our institutions of health care communicating with the government and communicating with the public, and it’s a problem in the exam room. As an example, if we are a strong believer in the importance of vaccination and we have a patient who is vaccine-hesitant, and we jump to showing them articles and telling them the data and what we think they need to know, we’re going to lose an opportunity to understand the perspective of the human in front of us, address their true concerns and fears, and come to an agreement where we move forward together as a team. Instead, we’ve created conflict between us and probably lost the trust of that patient.

Kevin Pho: So before we get to paths forward, of course, I’m interested in hearing about what you think we should do about this. How did we get to this point in the first place, in your opinion?

Jess Bunin: Well, as I mentioned upfront, I do think that there have been a lot of topics where we have declared that these are things we just don’t talk about in public spaces, and this has created this idea that it’s an “us and them.” I can’t talk to someone who has a different religion than I do. I can’t talk to someone across a political divide. I can’t talk to someone who doesn’t share my sexual orientation, whatever it may be. We’ve created these barriers around what it means to communicate.

I think in health care specifically, and in health care leadership and academia, we are taught from day one that it’s very important to be right, to know what you’re talking about, and to show you know what you’re talking about—that you’re the expert, that you’re the boss, that you’re making the decisions, and you have the right answer. We’re not taught to step back and think maybe we’re wrong. And so we’ve taken to this idea of debate and conflict instead of effectively listening to each other. We try to change each other’s minds and bring people to our side with data, and it just doesn’t work.

So that’s a big part of this conflict, I would say. The other part is we have this idea that civility means politeness and decorum and not challenging anyone and not pushing boundaries, and it’s just not true. In my mind, civil discourse is a whole system whereby we have to develop psychological safety, we have to practice active listening, and we have to find some common ground between us, even if it’s a value that we start with and branch out from there. We have to be willing to rethink our beliefs and assumptions, and we have to be able to challenge people in a way that’s going to build a relationship, not harm it. And I’m not sure we’re very good at those skills with our patients or in our systems.

As an example, the data shows us over and over that, in general, providers interrupt their patients within 11 to 18 seconds of them trying to tell us what’s wrong with them. That’s not nearly enough time. And I think if we watch people on rounds, it’s even less than that before folks are interrupting each other in a clinical space and within meetings. We’re not listening, we’re not hearing what they’re saying. We’re not hearing the meaning between the words. And so how can we have a conversation involving perspective-taking if we don’t know what the other perspective is?

Kevin Pho: And when you say that we are not good role models, and that patients, students, residents, and interns are not seeing good role models engaging in civil discourse, are you seeing that across the health care spectrum, ranging from administrators and leadership to attending physicians?

Jess Bunin: I am. I’m seeing it across the board. I don’t think that this is a problem in any one group or one type of person or one leadership position. I think it’s across professions. I think this is an interdisciplinary process within the profession of medicine. I think in many aspects, once there is a difference—whether that’s a difference between faculty and students, a difference between attending and resident, or a difference between nurse and physician, or in my context, military and civilian—all of those areas, we put up barriers. We’re afraid to share specific aspects of what we believe for fear of how the other person might take that.

And on the other side of that, individuals aren’t effectively creating the environment where they can sit and have the time to truly have deep conversations and listen to each other. I think time is one of our biggest barriers here, both in a clinical context in a 15- to 20-minute encounter with a patient, or in meeting scenarios. Often, we’re given a matter of minutes to brief slides or to tell a leader our concerns, and we don’t make the time to sit down, ask hard questions, and understand the perspectives of those around us.

Kevin Pho: So let’s get back to the anecdote that you shared with us earlier on where you were called in to mediate a dispute. So tell us how you navigated that and how you moved that scenario forward.

Jess Bunin: Yeah, that’s a great question. So, after refocusing myself, after doing some rethinking myself about what the actual problem was, we decided to create a series of workshops called “Community Building for Civil Discourse” for all of the staff and faculty at our institution. This allowed us to take a full day away from clinical encounters, from research obligations, from administrative burden, and spend the day truly getting to know each other. The morning of that workshop was built around restorative justice principles of community building, and the afternoon was spent working on all of those skills of civil discourse that I listed for you and doing activities around all of them.

Like, what are your weaknesses in developing psychological safety in your context? Why are you not actively listening? Where are your strengths and weaknesses, and what can you do to build that skill? What does it mean to find common ground, and how can we do that across differences when it feels like we’re all at these opposite ends of this political spectrum and everything is black and white? When we sit down and talk about it, there’s a lot of gray, and often that’s actually where we are.

And then this idea of rethinking. I don’t think it’s something we’ve ever been taught. I don’t think it’s something that’s comfortable to do. It requires a lot of humility, a lot of really examining the fact that maybe what I’ve grown to believe my whole life may not be a fact. It may not be a big truth. And then finally, learning some skills and practicing them together as a group where individuals can say, “You’ve said something that hurt my feelings, but I’d like to call you in and have a deeper conversation about that,” as opposed to calling you out and shaming you for doing it. When we call people out, if they’re not interested in having a professional relationship with us any longer, they want to avoid us. But if we call them in, now we’ve created a colleague. Now we’ve created an ally, and I think that’s where the power of this can be: creating allies across our differences where we can work together to solve big problems.

Kevin Pho: One of the things in your article that really resonated with me is that instead of trying to be correct, try to be curious instead. And I think that really is an important trait and characteristic of consensus-building. So talk more about that: trying to be curious rather than correct.

Jess Bunin: Yeah. We always say, “Get curious, don’t get furious,” when we hear of something happening that seems incredulous to us. But again, I’m going to go back to the fact that as providers, as physicians, we’re taught that it only matters to be correct. We’re graded on multiple-choice tests. We’re berated on rounds if we don’t know the right answer. So we’re pretty sure that we have to have the right answer or we’re going to get in trouble. And so we don’t take the time to ask for other perspectives. We don’t take the time to explore what that might mean.

It takes time to do that. It takes time to avoid allowing yourself to make assumptions, and instead, stopping and saying, “What don’t I understand about this situation? How can I build my knowledge? How can I be more genuinely curious about all of the possibilities of what could be happening instead of making assumptions about what I think is happening?” We do it about each other all the time. We make assumptions the second we meet or see someone because we’re embarrassed to ask them the right question. We don’t know how to ask them in a respectful manner, or we’re afraid it’s going to lead to conflict. So we make assumptions, and then we choose to avoid someone or spend more time with them based on the signals our brain is telling us about what’s comfortable and what’s uncomfortable. Instead, we need to step back and say, “I’m going to stop my assumptions. I’m going to ask the deeper, more important, curious questions.” This is what allows people to be great leaders: to truly get to know all of the people around them by asking curious questions.

Kevin Pho: So give us some outcomes of some of these principles in action. You could relate it back to the original anecdote that you shared with us, or a common scenario like talking to a patient who has philosophical differences with you in the exam room. It could be vaccines, it could be politics. What are some positive outcomes from some of this consensus-building that we’ve been talking about today? What would that look like?

Jess Bunin: Yeah, so what we’re actually seeing is folks are having an increased sense of belonging. They feel like their voice is heard in the institution and that they can contribute. And I think belonging is really key. The other thing we’re seeing is an increased sense of hopefulness about the future of the institution. If we can have belonging and hope for the future, we can accomplish anything together. So those are the two big outcomes.

On a smaller scale, what I’m actually seeing is people coming to me and saying, “What would be a more restorative way to handle this? What would be the right questions to ask in this scenario? How can I bridge this gap? I had this conflict with a student. How can I bridge the gap so that we can move forward together and they don’t feel isolated in my class?” Things along those lines. I don’t have broad ranges of numbers for how often that’s happening, but I’m hearing about it regularly, and I think that’s where the change happens. And I think when we teach our students and our faculty to do that, now they can bring that into the exam room.

I’ll give you an example. I approached a patient who was turned away from another emergency department while having a myocardial infarction. And I sat down and asked, “What do you think are all the reasons that this happened to you? Can we talk about this?” And she started crying and she opened up. She said, “No one’s ever stopped to ask me my perspective of what happened and why it mattered.” And when we stop and ask those questions and work on active listening, I let her then speak for five minutes without interrupting her, which is sort of unheard of in health care.

Kevin Pho: Speaking of role models, I think that a lot of people in society take cues from our politicians, right? Speaking of a lack of role models, they just speak in absolutes, they’re so dogmatic, and really not practicing anything that we’re talking about today. So my question to you is, how difficult is it to implement some of these ideas that we’ve been talking about today? Tell me about that process. Obviously, this is not an overnight thing, but tell me some of the challenges people face to adopt some of this consensus-building.

Jess Bunin: Yeah, well, I would argue that a lot of grandstanding and arguing and not listening—a lot of what we see is not how people interact on smaller scales on a regular basis, and we’ve normalized that behavior as OK. And I think we need to move away from that, which is another conversation. But I think we can start at all levels, working on small instances of how to build this so that we can continue to practice it and continue to learn it. Because when we talk about the last pillar of civil discourse that I talked about—the conversational skills and the skills to challenge each other—part of that is working on avoiding grandiose assumptions and hyperbolic language. As soon as we do that, we start excluding people, and they start tuning us out.

So if instead we can tone that down and again, start with the common ground, it’s a completely different conversation. It takes away the adversarial tension of a conversation right away. If we start at the same point, and I often tell people the best way to do that is to just share stories with each other, you’ll realize how much overlap you’ve had in life experiences, or the things you enjoy, or the way you experienced holidays or summer, or whatever the case may be. Even if there’s no overlap in your personal experiences, you can often find overlap in your values, whether that’s health care, whether that’s the dignity of humans, whether that is trust, loyalty, or life. We can all find a value we agree on, and then decide where our opinions take us from there and why our life experiences have made us believe that. If we can have that conversation starting with common ground, we avoid hyperbole, we avoid aggravating language, and we can instead have a true, meaningful conversation where we hear each other.

Kevin Pho: We’re talking to Jess Bunin, critical care physician and co-founder of All Levels Leadership. Today, the KevinMD article is “Civil discourse as a leadership competency: the case for curiosity in medicine.” Jess, let’s end with some take-home messages that you want to share with the KevinMD audience.

Jess Bunin: The most important thing is that if you can learn these pillars of civil discourse, these skills work everywhere. They work in your marriage. They work with your children. They work in a clinic. They work in leadership boardrooms. They work between hospitals and board leadership. It’s a universal skill that’s worth taking the time to learn. And once we learn the language of how to do that and to challenge each other constructively, we can make a lot of progress, from developing trust in that clinical encounter to developing trust within our institutions.

Kevin Pho: Jess, as always, thank you so much for sharing your perspective and insight, and thanks again for coming back on the show.

Jess Bunin: Thanks so much for having me. Have a wonderful day.