Sometimes I could just scream. There are other occasions when yelling feels good. And then there are the moments that speaking out fulfills the needs. Speaking up is a step down in volume and vigor, but it's a big step up from ordinary whining.

There is an obvious hierarchy of emotions and intensities of voice that climb as the causes become more frustrating or when solutions are farthest away. I "scream" about all the world injustices and human evils I can't control. I am at my loudest when I think about tin-toy generals killing their own subjects by inaction on top of the violent action of nature. These brutes don't hear my screams — nor the cries of the displaced as they slowly lose their strength and fall silent. But I also scream as the world allows them to fall silent.

I don't stop screaming at just those monsters. No, I scream at nation-ruining African dictators, warlords, South American megalomaniacs and homegrown American thugs wherever one may find them. Trust me. There is enough air in my lungs to go around.

The list of crimes against humanity that deserves a primordial scream from us include the tortures, killing and other acts of barbaric cruelty by any terrorist group or individual, be they in the name of totalitarian rule, the rule of their god, the failed rule of law usurped by tyrants or their own personal ego.

"Yelling," on the other hand, is for a flash of intensity. Yelling is what happens at fights, rallies, street demonstrations and riots — rigged or sincere. Sports crowds shout, but advocates for causes yell. When a group doesn't feel it is being heard, it will resort to yelling. That is why it is a key ingredient in futile political conversations. Yelling is used by both sides to raise their challenges but is also used to drown out the opponent. Being understood is not the issue, it is about being heard.

"Speaking out" is a stage of expression that is less piercing but a needed volume in this world of yelling and screaming. Speaking out is the means to bring action to the attention of the hard of hearing. Speaking out is the medium against injustice and inequity and awakens the insensitive and the sleeping giants to action. Speaking up is an important tool for the start of conversation of change. Speaking up is the way to share feelings and ideas and to identify oneself. Speaking up is the beginning of discovery as two strangers meet for the first time.

"Whining" is what a pediatrician is surrounded with all day long — if not by juvenile patients then by equally childish grown-ups. Whining turns off listeners and makes them want to stuff cotton in their ears. Complaining without solutions or sacrifice is whining. When I carp about health-care ills, I am not whining if I have to answer the phone at 3 a.m. and others in the system don't. Sleeplessness gives me some rights of speaking up and speaking out and even yelling that others haven't earned.

Remaining silent is the loudest noise of all. It is our silence that either makes us a hero or a co-conspirator. If we are quiet about injustice, we are collaborators. If we are silent about violence, we are voyeurs. If we are unspoken about abuses, we are cowards. If we say nothing about evil, we are sympathizers. But silence from the mouth of saints can be a testament against tyranny. Working in silence for the glory of others is sacrifice. Suffering in silence is selfless. Listening in silence is solidarity.

The trick is finding the right voice and the right tone at the right time. There are times to scream, times to yell, times to speak out, speak up and times to remain silent. However, when we want to make a personal difference, our voice must be quiet enough to listen and talk at the same time.

Joseph Cramer, M.D., is a fellow of the American Academy of Pediatrics, practicing pediatrician for more than 25 years and an adjunct professor of pediatrics at the University of Utah. He can be reached at [email protected]