MGMA Insights: Compliance, Consent, and the Psychology of Defiance
Download MP3Today we have Doctor Sunita Sa. Doctor. Sa, I want to get this right, is a tenured professor and organizational psychologist at Cornell University and also is the author of a new book, Defy.
Daniel Williams:We're gonna talk a lot about Defy as well as Doctor Sa's background. Doctor Sa, welcome to the show.
Dr. Sunita Sah:It's wonderful to be here, and please do call me Sunita.
Daniel Williams:Oh, Sunita. Okay. Well, great having you here, Sunita. And I see, well represented behind you, copies of Defy. I was telling you offline.
Daniel Williams:I had so much fun reading the book, learning about it. We're gonna talk about this book. But first, you have a little secret you divulge in the book that you are a big fan of the cure. That's right. Yes.
Daniel Williams:I'm a child of the eighties. Well, guess a child. I went to high school and college during the eighties. And so another fan of the cure. Tell me about that love for the cure and how that is defiant moment in your life.
Dr. Sunita Sah:Well, my parents hated the cure. But I love them. And I grew up, as I describe in DeFi, with a master class in compliance. Even my name, Sunita, I remember asking my dad at one point, what does that mean? And he was like, Sunita in Sanskrit means good.
Dr. Sunita Sah:And mostly I lived up to that. So I did How do you interpret the word good as a child?
Daniel Williams:I
Dr. Sunita Sah:did as I was told. I was polite. I went to school on time, I did all my homework as expected, I even had my hair cut the way my parents insisted. But yes, I did love The Cure. When I got to about the age of 16, I went to see The Cure three times.
Dr. Sunita Sah:It was my favorite band, and I remember actually backcombing my hair the way that Robert Smith does, and that did have my mum running down the driveway after me with hairbrush in hand thinking I'd forgotten to do something.
Daniel Williams:And just to elaborate on that, everyone. So, Sunita, tell us a little bit about that. You grew up you're in America. Now you're at Cornell, but you grew up in London, is that correct? Tell us a little bit about that background.
Dr. Sunita Sah:Sure. I grew up in Yorkshire in The UK, which is in the North Of England. Did move to London and spent ten years there before I moved to The US. But yes, I'm from the North, and my parents emigrated there. I grew up with learnings of these messages from, not just from parents, but from teachers and communities, like to be good, to obey, to fit in.
Dr. Sunita Sah:And we often teach our children these messages. And that actually led to my first career as well. In The UK, Medicine is a combined undergraduate and graduate degree. I had the grades and I was told medicine is the best thing you can do. So even though I was a little bit unsure about the clinical aspect of medicine, I'm a bit squeamish, but I ended up going to medical school and finishing medical school and working as a physician, which was really based on expectations, that first career.
Dr. Sunita Sah:So it took a couple of steps to get to where I am now, working as a professor at Cornell University, and delving into this research on advice, why we take bad advice, and compliance and defiance.
Daniel Williams:Right. And so in addition to talking about your love for the cure there, you have a wonderful illustrated story at the beginning where you're in a medical setting, you have clinicians talking to you about taking some tests. I don't want to get anything wrong from there. So walk us through what happened and what went through your mindset, to use that as an illustration in this book?
Dr. Sunita Sah:I think it was a couple of years after I had moved to The US. And I was experiencing some chest pain. And it was a kind of pain that I had not experienced before. So I was a little bit worried about it. And I ended up going to the emergency room and I was whisked through triage.
Dr. Sunita Sah:It went so fast. And there was loads of tests being done, including an electrocardiogram, which was fine. It turned out to be fine. That was the main thing that I was concerned about, anything sort of going on with my heart. And the pain was actually subsiding.
Dr. Sunita Sah:So I was thinking I would be discharged. And then I was told, well, actually, before we let you go, we should do a CT scan. And I was like, why? Why do I need a CT scan? Like this contrast CT scan, which has quite a bit of radiation, about 70 times more on average than an x-ray, but still is small, but it's still a significant amount.
Dr. Sunita Sah:And they said, We want to make sure that you don't have a pulmonary embolism. Now, this type of embolism is a blood clot in the lungs. I used to work in what we call respiratory medicine in The UK. I think it's pulmonary here. And it has a particular type of pain, what we call pleuritic chest pain.
Dr. Sunita Sah:So it catches your breath when you breathe in, when you breathe out, it's very sharp, stabbing. I was not having that type of pain. So I was pretty certain I did not have a pulmonary embolism. And so why would I expose myself to ionizing radiation if I didn't need it? I should have said no to that scan, and I couldn't do it at all.
Dr. Sunita Sah:And the only reason I went along and had it was because the doctor told me so. And the whole time that the scanner was going, I was so perplexed. Why couldn't I just say, I'd rather not have the scan? And I just didn't want to make a fuss. I didn't want to be the difficult patient.
Dr. Sunita Sah:I didn't want to be questioning the doctor's opinion. And after I walked out of that hospital, and of course the scan showed my very healthy lungs, I just thought, why did that happen? Why couldn't I say no in an environment where informed consent is pretty high on their list of priorities? Why did I feel I couldn't say no in that situation? And I was really fascinated by that.
Dr. Sunita Sah:And some of my research was already looking at that type of compliance in medical environments. It spread to other types of environments too. But I really was fascinated by how difficult it was for me to say no in that situation and what we can do to help not just patients choose correctly, but all of us in everyday decisions that we make in life.
Daniel Williams:Right. We're going to cover a lot of aspects of the book in your research, but let's stay with this health care side because this isn't to be political about it, but there are a lot of challenges going on right now in health care. We saw it, you know, do we mask during COVID? Do we not mask? Do we get a shot?
Daniel Williams:Do we not get a shot? Or do we take other types of remedies, so to speak, to protect ourselves or others? You had a particular experienced viewpoint of what was going on, you being a physician, you knew a little bit more than or a lot more than your average person would, where is it where we are really following our compass there versus having an informed background versus, oh, this is an expert. They tell me to do this. I'm going to do exactly what they say no matter what they say.
Daniel Williams:And I am embarrassed almost to say I don't recall if you touch on that specific aspect in the book, but I would love to know your thoughts on that aspect because it is a real challenge right now about do we question authority or do we get a second or a third or a fourth opinion? What do we do and how do we handle Yeah,
Dr. Sunita Sah:and that's a great question. And it's a discussion that I have a lot with my health care leadership class with my students. And half the class are senior physicians, the other half work in healthcare too. And medicine, we have a high level of trust in our doctors, and it would be a shame for that trust to disappear. But sometimes, do they know exactly what's right for a particular individual?
Dr. Sunita Sah:Sometimes it is good to question, and I'll tell you the situations where I think that's the right thing to do. So I differentiate in the book between compliance and consent. So compliance is something that you slide into, externally imposed. So somebody telling you, giving you a suggestion, an order, or even society's expectations. You should do medicine.
Dr. Sunita Sah:It's the best thing you can do. That is compliance. Now, if we think about consent, we can actually take the definition of informed consent in medicine and apply it to the decision that I was making and that other people make. And that requires five elements. We often conflate both compliance and consent, but they are fundamentally different.
Dr. Sunita Sah:So for consent, or what I call your true yes, you need five elements. So you need capacity. Physicians will assess patients for their mental capacity, that they're not too sick, they're not under the influence of drugs or alcohol. So that's the first one. The second one is knowledge.
Dr. Sunita Sah:You need information about that decision that you're going to make. But it's not enough just to have the information. You need to have a full understanding of that information. So a real grasp of the facts, the risks, the benefits, the alternatives, and that includes the source, the accuracy of the information, which I think is one of the difficult things that we're facing in today's age. It's like, what is this information?
Dr. Sunita Sah:Is it accurate? How much do we Especially with the amount of misinformation that's around these So we have capacity, knowledge, understanding. The fourth element is the freedom to say no, because if you don't have the freedom to say no, then it's merely compliance, it's not consent. And if those four elements are present, then you can give your authorization, which is your thoroughly considered authorization of your deeply held values. So if you want to say yes, that's your true yes, that's consent.
Dr. Sunita Sah:If you want to say no, that's your informed refusal or defiance. And in that particular situation with a CT scan, I did have the knowledge and understanding. So I could give a true yes or a true no. I did have the freedom to say no, like nothing would have happened. This isn't exactly the type of environment where you ask for patient autonomy.
Dr. Sunita Sah:And I could have said no, and yet I didn't. And that is what is so fascinating about this, is when all the elements for consent are present, why do we say yes when we actually mean no?
Daniel Williams:Right. Let's look at it again from the healthcare side of it. Patients are in situations where the clinician is telling them this is what is. And as you say in your book, often the patients don't question it. Let's not even think about question may or may not be the right way to even say it, but to at least have a conversation about it like, is this right for me?
Daniel Williams:Can I consult with my family? Can I talk to someone else just so it could be a I don't mean a high pressure situation like this is a used car lot, nothing against used cars, but I mean, where they won't let you off the lot, you gotta do this? Hopefully, in our medical field, that would not be in that kind of a high pressure situation. You've gotta do this right now. But some people in an ER it might be a very high pressure situation where something needs to be done, a really difficult decision might need to be made.
Daniel Williams:So in that scenario, what can the patient do to get the right kind of information they need in that moment to have the conversation they need to have with that medical staff there or with other people that are trusted within their circle?
Dr. Sunita Sah:Yeah, so in these situations, they can be high precious situations. Of patients have spoken to me about how they feel that their physician is always so busy, and they say something and they don't feel that they have the room to question. And this goes with one of the psychological processes that I've discovered in my research that I call insinuation anxiety. When somebody is supposed to have your best interests at heart like doctors, it is very difficult to say no because it insinuates that they cannot be trusted, which is something that we don't want to do, especially to a physician. So insinuation anxiety is this fear of implying anything negative to someone, especially when they're standing right in front of you.
Dr. Sunita Sah:So doctors do have specialized knowledge. We can't all go to medical school and have all the knowledge and the understanding of that information. But some patients have twenty years of experience with their particular illness that the doctor, A, might not be aware of, or really understand what is important to them. And as we know, there's different types of there's different ways to practice medicine. Some people, some patients will prefer paternalistic medicine, just being told what to do, because that is their preference.
Dr. Sunita Sah:Others want shared decision making. Others want a guide, a coach, as in here are the different options. So there is a patient preference aspect of that. But what I think is really interesting when there was the whole movement about ten years ago for patients to choose wisely, when there were various medical interventions or procedures that they encouraged patients to question, such as surgery for lower back pain. How can we actually expect patients to do this when it's so difficult to question the doctor?
Dr. Sunita Sah:And why should the burden fall on the patient at this point? So these are questions that I think are very important in medicine. And I think it's also important for both doctors and patients to understand some of the psychological processes that go on between that relationship, that interaction, when they're being told, yes, you should have a CT scan, or you should have this procedure, or you should have surgery. How patients, possible, so it's not like a crisis moment where you have to make a decision on the spot, where honestly, you just have to give your trust to the doctor in those situations, unless you really feel something is wrong. But in situations, can you take what I call the power of the pause, which is not to decide straight away?
Dr. Sunita Sah:Even if I had said, let me think about it for a few minutes, I might have made a different decision. But I was immediately wheeled through to the scanner and left there. And it just felt, oh, is too late now to say no, the process is happening. So just asking for a few minutes to think about something or taking a step back and thinking, is this really the right thing for me? What are the alternatives?
Dr. Sunita Sah:And if the doctor doesn't have time to answer those questions, maybe that is a time to step out and do some research on your own. I've also found, and people might relate to this, that it's far easier for me to ask for a second opinion when it's for my child than it is for myself. And this is really about how do we connect with our responsibility, because sometimes we are willing to give away our agency when it's about ourselves. But if it's about a loved one, then you know I'm responsible here. I really have to make sure this is the right thing.
Dr. Sunita Sah:So if we can lean into those situations that this is what we would advise a loved one, or this is what we would want, then we should also advocate for ourselves in the same way.
Daniel Williams:Right. What's going on psychologically within us where we are very protective of those we love? And then ourself, we go, yeah, sure, I'll go right along with you. Why do we not protect ourselves in the same way?
Dr. Sunita Sah:Because it's really hard. If you have been socialized to be compliant, it becomes almost our default response to say yes and be compliant. And we start equating being compliant with being good and defiance with being And in that situation, the next time I was called to have an unnecessary scan, I did say no because I had thought about it. I'd visualized what I wanted to say. I practiced it.
Dr. Sunita Sah:I tried to change those neural pathways of just my automatic yes. And even with that, I felt like I was being the difficult patient, not going along with how the clinic is running or what they recommend. And we want to avoid those types of things. But if you are showing that you're connecting with your responsibility for a loved one and a child, it's not seen as a negative thing. It's seen as like you want to do the right thing, and of course you're concerned about it.
Dr. Sunita Sah:And so we process all these things in a particular way of, here I know my responsibility is for a loved one, but can we connect with that responsibility for ourselves? Who exactly are we responsible for? Is it just our loved ones? Is it for ourselves? Is it for a community?
Dr. Sunita Sah:And really for me as a physician in those situations, it's all of those things. Because I am a physician, and I do believe in the general principles of medical ethics. And maybe the medical system doesn't change when I say no, but I did have an experience a year later where I decided to say no to an x-ray that came before I saw the doctor, and not have an investigation before I've seen the doctor. And when I told a few people about this, they were like, Oh, you should write that up. And in the end, I did write it up for JAMA Internal Medicine, and that flooded my inbox with so many emails.
Dr. Sunita Sah:And some were like, You're absolutely right. Others were, This is the most efficient way to run a clinic, and I'm more interested in quality of care rather than efficiency of care. I know both are important, but if one is going to trump the other, it should be the quality of care. And others saying, well, the system has to change before we do. And even if rejecting something doesn't change the doctor's behavior or how they run a clinic, if somebody else was to do the same thing, maybe they would think twice.
Dr. Sunita Sah:So it does start off with individual actions that can eventually make a difference. It has a ripple effect.
Daniel Williams:Okay. Now you said something earlier that, and I saw it in your bio as well, that you do teach at Cornell healthcare leadership. If I heard you correctly, there are quite a few physicians in the course,
Dr. Sunita Sah:is that That's correct.
Daniel Williams:How has that helped you inform your research, your thoughts on this act of defiance, so to speak? And then what have they learned from you? Is there anything you can share, an anecdote or anything you've learned from that interaction with a class of many of them being physicians?
Dr. Sunita Sah:Yeah, about 50% of the class are physicians that have been out of medical school for about ten years. And they come and they get a dual degree, both from the business school and the medical school. So it's a wonderful program. I love teaching those students, and they're so keen to learn. When I teach healthcare leadership, we cover many aspects, including values, which is really important.
Dr. Sunita Sah:Because a lot of them are connected with their values due to the work that they do, and it's usually due to an early experience in their lives, in young adulthood or even in childhood. And they have these very strong values. But often what I've seen in my research as well in the class is that how we think we behave in a certain situation is quite different from how we actually behave. So we think we're going to do the right thing, but when we're in a particular situation, we freeze, or we're uncertain, and we don't connect with our values. So there have been some horrific stories that I've heard in the classroom, of course, especially during the pandemic.
Dr. Sunita Sah:Some of the students found it very difficult to talk about. They were first line in the emergency rooms during the pandemic in New York City. And they found it very difficult to talk about for a few years after that. And we did have some harrowing cases within their own classroom and things that were happening. And this aspect of how do we speak up in these situations that are really critical and really important became the focus of one of our class discussions.
Dr. Sunita Sah:So if you think about one of the reasons why I think this is so important to study is when I started delving into it, I found that there was one study that found that nine out of ten healthcare workers on average, most of them nurses, did not feel comfortable speaking up when they see a colleague or a physician making an error. So this is the dangers of just going along with things, not speaking up, just swallowing how we feel, and basically being so compliant. It really made me start to think, is it sometimes bad to be so good, to be so polite, so compliant, so agreeable? And what do we actually sacrifice by disregarding our values so often?
Daniel Williams:Okay. Thank you so much for that. Before we sign off, have another question. You have a term in the book called false defiance. Explain that to us, because I was trying to get a handle on that.
Daniel Williams:What can you say about false defiance?
Dr. Sunita Sah:So if we think about what defiance actually is, which we need those five elements, the same elements that we need for consent. False defiance is something that looks like defiance on the surface, but it's really not. It's done for performative reasons or other reasons. So I have a teenage son, and he often does the exact opposite. Or he at least went through a phase of doing the exact opposite of what I asked him to do.
Dr. Sunita Sah:So it was oppositional. And I thought it was really fascinating because what that really shows, if somebody does the exact opposite of what you ask them to do, it looks like defiance. But he is listening so intently to what I want, to be able to do the exact opposite. It's totally reliant on me. He's relying on me.
Dr. Sunita Sah:So this is false defiance. It looks like defiance, but it's not coming from an internal consideration of our deeply held values. Again, it's an external force like compliance. So like compliance, false defiance is really that type of following somebody else's preferences, even if it's doing it in the opposite direction. And we see this also play out on social media, that people will say things just to be controversial or to get lots of likes.
Dr. Sunita Sah:It's very performative. It's not done because of a deeply held value. And sometimes we can get caught up in that. We can go to a march or a protest just because all our friends are, rather than the fact that we actually believe in a particular cause. So we do need to be careful not to fall into the trap of false defiance.
Daniel Williams:Yeah. Last question then. Let's talk about real defiance. You use historical figures, Rosa Parks, Colin Kaepernick, and others in your book. They did have convictions.
Daniel Williams:They did stand by particular values that they had. Talk about how medical practice professionals and leaders can learn from those historical figures and integrate that into their own lives and have their own acts of defiance, so to speak.
Dr. Sunita Sah:And I think this is one of the things that we think about when we think about defiance, is Rosa Parks' famous No on the bus. I'm not going to move for a white passenger. And we often think of defiance as being negative, loud, angry, or superhuman and heroic, like Rosa Parks and Colin Copernic. But it doesn't have to be. If we think about Rosa Parks' No on the bus, it was preceded by hundreds of moments of compliance.
Dr. Sunita Sah:There were many times she complied with segregation laws on the bus. That time she decided not to. She connected with her values for equality and decided this was the time. So there's two questions that I believe that in my research that I've seen in hospitals as well from nurses and nurse managers, two questions that nurses ask themselves about whether to speak up or not. And the two questions are, is it safe and will it be effective?
Dr. Sunita Sah:So they do talk about safety, which could be psychological safety, but also what would be the impact on my job if I reported this error or how would I be treated? And so there is that element of safety. But also I heard, I'm not scared about speaking up, but nothing ever changes. I've spoken up so many times, but this still happens. And so they give up hope in speaking up.
Dr. Sunita Sah:If we go back to Rosa Parks on the bus, was it safe and was it effective for her to speak up? Well, it's never 100% Defiance has some element of risk to it. And for Rosa Parks, it was not safe at all. She was living in a time where she received death threats from her defiance in this situation. So it's very individual choice as to how we assess safety and whether it's going to be effective or not.
Dr. Sunita Sah:Colm Copernic didn't know whether it's going to be effective if he sat down or if he took a knee. But sometimes we just stand or we sit or we kneel based on our principles rather than whether it's going to be effective or not. But both of those actions had a ripple effect and it was important. So the thing to take away here is really understanding who you are, what your values are and what you stand for, and being able to connect with those. And then you make your own judgment of your, so your defiance calculus in a way of what do you need?
Dr. Sunita Sah:Because the question we should be asking, is it safe enough? Is it effective enough? Rather than is it safe or is it effective?
Daniel Williams:Right. Last thing I'm gonna add then, everybody, I had the opportunity to both read and listen to Defy over the past weekend. And, Sunita, you do the audio. You are the narrator of the book. I do wanna ask you.
Daniel Williams:I've mentioned that to you offline, but what was that experience like? You've done some acts of defiance and stepping out. That seems like a new enterprise for you. What was that like?
Dr. Sunita Sah:So it was certainly an amazing experience in a way. It was something new for me. I had an amazing director who would speak to me over the headphones. And she guided me a lot, so that was really important to have. But I felt it was important for me to read the words.
Dr. Sunita Sah:I thought readers would be able to connect more with the message if it was the author doing it. I am not a professional audio reader, so it was an experience but a great one to have. And certainly I've heard lots of great things from people who have listened to the audio, and at least one close friend saying that she's listened to it four times now. So that really touches me and it means a lot. That in any way that you prefer to receive information, whether it's audio or reading, the important thing is that I want to give people the tools to make Defiance accessible to everyone.
Dr. Sunita Sah:Because I think it's a really necessary skill set for us to have.
Daniel Williams:Yeah. I've talked about this on the podcast before. We have a book club that I moderate at MGMA. It's available to MGMA members. We have to fi on the list for later this So anybody listening, please be on the lookout for that or send me an email, get in touch with me, and we'll get you on that book club as well.
Daniel Williams:And I will concur with what your friend said. You I consume a lot of books, both in print and I listen to them as well. And you did an amazing job because I really do grade not only what are the words that are on the page or that you hear being said, but also the voice of the narrator. And you did great job. I mean that was really impressive.
Dr. Sunita Sah:Thank you so much. Really appreciate those words. Thank you.
Daniel Williams:Yeah. Well, doctor Sunitas, I do wanna thank you for joining us on the MGMA podcast. I'm so glad that I I I think I learned about you on LinkedIn months ago. I think the book was either had just come out or was coming out. And somehow one of the MGMA members or someone else in my healthcare sphere had posted something about it.
Daniel Williams:I said, I've got to get you on the show. And so I'm so glad you're here. Thank you for joining us.
Dr. Sunita Sah:Thank you very much. It was wonderful to speak with you.
Daniel Williams:Yeah. So that is going to do it for this episode of MGMA Insights podcast, everyone. I'm going to put direct links to both Doctor. Sa's website as well as places where you can access and purchase the book as well. So until then, thank you all for being MGMA podcast listeners.
