By Robert L. Moore, MD, MPH, MBA, Chief Medical Officer
“The single biggest problem in communication is
the illusion that it has taken place.”– George Bernard Shaw, Irish playwright and critic
In 2022, Plumas District Hospital in Quincy closed their maternity unit. While there were many factors that contributed to this event, the final cause was a shortage of nurses to staff the unit, and this shortage was exacerbated by a mis-framing of what constitutes safe care in rural areas. How did this happen?
Across healthcare, as in the wider public and political world, certain phrases can function less as invitations to think together and more as signals that discussion should stop. For physician leaders in primary care and rural systems, that matters. The words teams choose when they disagree can either surface risk, clarify uncertainty, and improve care—or harden hierarchy, shut down dialogue, and leave the real problem untouched.
One of the most useful structured tools for speaking up is CUS: Concerned, Uncomfortable, and Safety. In TeamSTEPPS-based communication (and featured in the American Academy of Family Physicians training curriculum: Advanced Life Support in Obstetrics), these words are meant to escalate a patient safety concern in a recognizable, shared way. Using this too, one progresses from “I’m uncomfortable,” to “I’m concerned,” to “This is a safety issue,” to jar the clinician higher up in the hierarchy into changing from quick, reflexive thinking to slow, thoughtful thinking.
These CUS words help a nurse, physician, or any team member move from raising a concern to signaling that a true safety issue may be present and needs immediate attention. Used well, CUS does not challenge authority for its own sake; it supports mutual respect, advocacy, and safer care.
But physician leaders should also recognize the risk of misapplication. Not every expression of discomfort represents a safety threat. Sometimes the issue is not that the plan is unsafe, but that a staff member is unfamiliar with the task, the workflow, the patient population, or the clinical rationale. If the language of CUS is used inaccurately in those moments, leaders can be pulled into conflict about authority rather than inquiry about competence, training, and support. The better leadership response is to separate these questions: Is this truly a safety concern, or is this a signal that someone needs coaching, clarification, supervision, or skill development?
A similar pattern is increasingly heard through the phrase, “not on my nursing license.” At times, that statement reflects a legitimate concern about scope, preparation, or unsafe delegation and should be taken seriously. Yet it can also be used too broadly, as a conversation-ending phrase that obscures the real issue. In rural settings, where staffing is lean and care models depend on flexibility, many nurses are cross-trained and practice capably across a wider range of responsibilities.
The question is often not whether an activity is categorically outside nursing, but whether the individual nurse is competent, supported, and practicing within policy, training, and available backup. Rural leaders know that high-quality care sometimes depends on clinicians working in a legitimate zone of discomfort without crossing into unsafe practice. That is different from asking staff to work beyond training. The leadership task is to create enough clarity that teams can distinguish between four very different situations: true patient danger, professional scope limits, individual lack of competence, and ordinary discomfort that accompanies growth in a resource-constrained environment. When those categories are blurred, safety language becomes less credible, teamwork becomes more brittle, and patient care can be delayed.
For clinician leaders, the goal is not to discourage speaking up. It is to preserve the meaning of speaking-up language so that it remains trusted when danger is real. CUS words should retain their power for patient safety, and concerns about licensure should remain grounded in actual scope and competency issues—not become reflexive ways to halt discussion. Especially in rural care, where teams rely on trust, adaptability, and shared problem-solving, the challenge is to keep important words from derailing the very high-quality care they were meant to protect.
We hope that Plumas District Hospital will open an alternative birthing center and flexible perinatal unit in 2027. They know from first-hand experience that they will only be successful if the whole clinical team (including the Emergency Department) gains knowledge and training to maintain skills in a low volume setting, and they can narrate their discomfort in a way that supports building competency, instead of closing down services in frontier areas.