Frontline staff are routinely encouraged to report patient safety problems, but many feel discouraged by management's response, or lack thereof, and thus they stop reporting. In this study, physicians reported three major barriers to speaking up: organizational deafness, disconnect between frontline staff and managers, and management denial of issues raised. As a result, physicians experienced burnout, moral injury, and job dissatisfaction. Fostering clear feedback pathways, genuine connection between physicians and managers, and an organizational commitment to accountability may increase physician willingness to speak up about patient safety concerns.