Can we learn civility? Reflections on the challenge of changing culture.

Academic medicine shares the handicap of many hierarchical organizations in that it is difficult for those lower in the hierarchy to speak up when doing so requires challenging their chronologic and administrative elders. Elsewhere in this issue, Dankoski and colleagues offer specific recommendations for combating this "organizational silence," including training and mentorship for junior faculty. In this related Commentary, the authors cite their lack of success with isolated initiatives to address the problem of organizational silence in their own institution. They suggest that nothing short of a comprehensive, visible, high-priority organizational commitment to culture change is likely to be effective in facilitating respectful and candid communication up and down the academic hierarchy. Until the culture of academic medicine affirms that broad input is vital, learners and junior faculty are unlikely to feel safe in expressing concerns, providing feedback, reporting mistreatment or unprofessional behaviors, and offering suggestions for improvement.