May 28, 2025 • 33 mins
In this MGMA Insights podcast episode, Daniel Williams sits down with Dr. Sunita Sah, a tenured professor at Cornell University and author of Defy. Together, they explore the subtle but powerful psychology behind compliance and informed consent. Drawing from her experiences as a physician and organizational psychologist, Dr. Sah discusses why patients — and even medical professionals — often follow advice they disagree with, and how we can build greater confidence, clarity, and autonomy in healthcare decision-making.
[00:04:00] The Scan She Didn’t Want
- Dr. Sah tells a personal ER story that sparked her research into why we comply, even when we know we shouldn't.
[00:09:00] The Five Elements of True Consent
- A breakdown of capacity, knowledge, understanding, freedom to say no, and personal authorization — and how this differs from compliance.
[00:14:00] Why It’s Hard to Speak Up
- “Insinuation anxiety” is the discomfort we feel when we risk questioning those in power — even when the stakes are high.
[00:20:00] Leadership Lessons from Healthcare Classrooms
- Dr. Sah shares how physicians in her Cornell classes are rethinking how they lead and communicate through values-driven decision-making.
[00:24:00] False Defiance vs. Real Defiance
- Not all resistance is rooted in values. Dr. Sah explains how to recognize the difference between performative opposition and meaningful dissent.
Resources:
- Dr. Sunita Sah’s Website
- Defy by Dr. Sunita Sah - Buy on Amazon or Listen on Audible
- Join the MGMA Book Club — Defy is featured in an upcoming session
- More MGMA Insights Episodes
Additional Resources:
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Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Daniel Williams (01:04):
Today we have Doctor Sunita Sa. Doctor. Sa, I
want to get this right, is atenured professor and
organizational psychologist atCornell University and also is
the author of a new book, Defy.
We're gonna talk a lot aboutDefy as well as Doctor Sa's
background. Doctor Sa, welcometo the show.
Dr. Sunita Sah (01:24):
It's wonderful to be here, and please do call
me Sunita.
Daniel Williams (01:28):
Oh, Sunita. Okay. Well, great having you
here, Sunita. And I see, wellrepresented behind you, copies
of Defy. I was telling youoffline.
I had so much fun reading thebook, learning about it. We're
gonna talk about this book. Butfirst, you have a little secret
you divulge in the book that youare a big fan of the cure.
(01:51):
That's right. Yes.
I'm a child of the eighties.Well, guess a child. I went to
high school and college duringthe eighties. And so another fan
of the cure. Tell me about thatlove for the cure and how that
is defiant moment in your life.
Dr. Sunita Sah (02:08):
Well, my parents hated the cure. But I love them.
And I grew up, as I describe inDeFi, with a master class in
compliance. Even my name,Sunita, I remember asking my dad
at one point, what does thatmean? And he was like, Sunita in
Sanskrit means good.
(02:30):
And mostly I lived up to that.So I did How do you interpret
the word good as a child?
Daniel Williams (02:36):
I
Dr. Sunita Sah (02:37):
did as I was told. I was polite. I went to
school on time, I did all myhomework as expected, I even had
my hair cut the way my parentsinsisted. But yes, I did love
The Cure. When I got to aboutthe age of 16, I went to see The
Cure three times.
It was my favorite band, and Iremember actually backcombing my
(03:00):
hair the way that Robert Smithdoes, and that did have my mum
running down the driveway afterme with hairbrush in hand
thinking I'd forgotten to dosomething.
Daniel Williams (03:12):
And just to elaborate on that, everyone. So,
Sunita, tell us a little bitabout that. You grew up you're
in America. Now you're atCornell, but you grew up in
London, is that correct? Tell usa little bit about that
background.
Dr. Sunita Sah (03:24):
Sure. I grew up in Yorkshire in The UK, which is
in the North Of England. Didmove to London and spent ten
years there before I moved toThe US. But yes, I'm from the
North, and my parents emigratedthere. I grew up with learnings
of these messages from, not justfrom parents, but from teachers
(03:46):
and communities, like to begood, to obey, to fit in.
And we often teach our childrenthese messages. And that
actually led to my first careeras well. In The UK, Medicine is
a combined undergraduate andgraduate degree. I had the
grades and I was told medicineis the best thing you can do. So
even though I was a little bitunsure about the clinical aspect
(04:09):
of medicine, I'm a bitsqueamish, but I ended up going
to medical school and finishingmedical school and working as a
physician, which was reallybased on expectations, that
first career.
So it took a couple of steps toget to where I am now, working
as a professor at CornellUniversity, and delving into
(04:30):
this research on advice, why wetake bad advice, and compliance
and defiance.
Daniel Williams (04:37):
Right. And so in addition to talking about
your love for the cure there,you have a wonderful illustrated
story at the beginning whereyou're in a medical setting, you
have clinicians talking to youabout taking some tests. I don't
want to get anything wrong fromthere. So walk us through what
(04:58):
happened and what went throughyour mindset, to use that as an
illustration in this book?
Dr. Sunita Sah (05:04):
I think it was a couple of years after I had
moved to The US. And I wasexperiencing some chest pain.
And it was a kind of pain that Ihad not experienced before. So I
was a little bit worried aboutit. And I ended up going to the
emergency room and I was whiskedthrough triage.
It went so fast. And there wasloads of tests being done,
(05:27):
including an electrocardiogram,which was fine. It turned out to
be fine. That was the main thingthat I was concerned about,
anything sort of going on withmy heart. And the pain was
actually subsiding.
So I was thinking I would bedischarged. And then I was told,
well, actually, before we letyou go, we should do a CT scan.
(05:50):
And I was like, why? Why do Ineed a CT scan? Like this
contrast CT scan, which hasquite a bit of radiation, about
70 times more on average than anx-ray, but still is small, but
it's still a significant amount.
And they said, We want to makesure that you don't have a
pulmonary embolism. Now, thistype of embolism is a blood clot
(06:13):
in the lungs. I used to work inwhat we call respiratory
medicine in The UK. I think it'spulmonary here. And it has a
particular type of pain, what wecall pleuritic chest pain.
So it catches your breath whenyou breathe in, when you breathe
out, it's very sharp, stabbing.I was not having that type of
pain. So I was pretty certain Idid not have a pulmonary
(06:34):
embolism. And so why would Iexpose myself to ionizing
radiation if I didn't need it? Ishould have said no to that
scan, and I couldn't do it atall.
And the only reason I went alongand had it was because the
doctor told me so. And the wholetime that the scanner was going,
I was so perplexed. Why couldn'tI just say, I'd rather not have
(06:58):
the scan? And I just didn't wantto make a fuss. I didn't want to
be the difficult patient.
I didn't want to be questioningthe doctor's opinion. And after
I walked out of that hospital,and of course the scan showed my
very healthy lungs, I justthought, why did that happen?
Why couldn't I say no in anenvironment where informed
(07:21):
consent is pretty high on theirlist of priorities? Why did I
feel I couldn't say no in thatsituation? And I was really
fascinated by that.
And some of my research wasalready looking at that type of
compliance in medicalenvironments. It spread to other
types of environments too. But Ireally was fascinated by how
(07:43):
difficult it was for me to sayno in that situation and what we
can do to help not just patientschoose correctly, but all of us
in everyday decisions that wemake in life.
Daniel Williams (07:53):
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 tobe political about it, but there
are a lot of challenges going onright now in health care. We saw
it, you know, do we mask duringCOVID? Do we not mask? Do we get
(08:14):
a shot?
Do we not get a shot? Or do wetake other types of remedies, so
to speak, to protect ourselvesor others? You had a particular
experienced viewpoint of whatwas going on, you being a
physician, you knew a little bitmore than or a lot more than
(08:35):
your average person would, whereis it where we are really
following our compass thereversus having an informed
background versus, oh, this isan expert. They tell me to do
this. I'm going to do exactlywhat they say no matter what
they say.
And I am embarrassed almost tosay I don't recall if you touch
(08:59):
on that specific aspect in thebook, but I would love to know
your thoughts on that aspectbecause it is a real challenge
right now about do we questionauthority 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 (09:15):
and that's a great question. And it's a
discussion that I have a lotwith my health care leadership
class with my students. And halfthe class are senior physicians,
the other half work inhealthcare too. And medicine, we
have a high level of trust inour doctors, and it would be a
shame for that trust todisappear. But sometimes, do
(09:38):
they know exactly what's rightfor a particular individual?
Sometimes it is good toquestion, and I'll tell you the
situations where I think that'sthe right thing to do. So I
differentiate in the bookbetween compliance and consent.
So compliance is something thatyou slide into, externally
(10:02):
imposed. So somebody tellingyou, giving you a suggestion, an
order, or even society'sexpectations. You should do
medicine.
It's the best thing you can do.That is compliance. Now, if we
think about consent, we canactually take the definition of
informed consent in medicine andapply it to the decision that I
(10:22):
was making and that other peoplemake. And that requires five
elements. We often conflate bothcompliance and consent, but they
are fundamentally different.
So for consent, or what I callyour true yes, you need five
elements. So you need capacity.Physicians will assess patients
for their mental capacity, thatthey're not too sick, they're
(10:44):
not under the influence of drugsor alcohol. So that's the first
one. The second one isknowledge.
You need information about thatdecision that you're going to
make. But it's not enough justto have the information. You
need to have a fullunderstanding of that
information. So a real grasp ofthe facts, the risks, the
(11:05):
benefits, the alternatives, andthat includes the source, the
accuracy of the information,which I think is one of the
difficult things that we'refacing in today's age. It's
like, what is this information?
Is it accurate? How much do weEspecially with the amount of
misinformation that's aroundthese So we have capacity,
(11:26):
knowledge, understanding. Thefourth element is the freedom to
say no, because if you don'thave the freedom to say no, then
it's merely compliance, it's notconsent. And if those four
elements are present, then youcan give your authorization,
which is your thoroughlyconsidered authorization of your
(11:46):
deeply held values. So if youwant to say yes, that's your
true yes, that's consent.
If you want to say no, that'syour informed refusal or
defiance. And in that particularsituation with a CT scan, I did
have the knowledge andunderstanding. So I could give a
true yes or a true no. I didhave the freedom to say no, like
(12:07):
nothing would have happened.This isn't exactly the type of
environment where you ask forpatient autonomy.
And I could have said no, andyet I didn't. And that is what
is so fascinating about this, iswhen all the elements for
consent are present, why do wesay yes when we actually mean
(12:28):
no?
Daniel Williams (12:29):
Right. Let's look at it again from the
healthcare side of it. Patientsare in situations where the
clinician is telling them thisis what is. And as you say in
your book, often the patientsdon't question it. Let's not
even think about question may ormay not be the right way to even
(12:52):
say it, but to at least have aconversation about it like, is
this right for me?
Can I consult with my family?Can I talk to someone else just
so it could be a I don't mean ahigh pressure situation like
this is a used car lot, nothingagainst used cars, but I mean,
(13:15):
where they won't let you off thelot, 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 itmight be a very high pressure
situation where something needsto be done, a really difficult
decision might need to be made.
(13:36):
So in that scenario, what canthe patient do to get the right
kind of information they need inthat moment to have the
conversation they need to havewith that medical staff there or
with other people that aretrusted within their circle?
Dr. Sunita Sah (13:52):
Yeah, so in these situations, they can be
high precious situations. Ofpatients have spoken to me about
how they feel that theirphysician is always so busy, and
they say something and theydon't feel that they have the
room to question. And this goeswith one of the psychological
processes that I've discoveredin my research that I call
(14:12):
insinuation anxiety. Whensomebody is supposed to have
your best interests at heartlike doctors, it is very
difficult to say no because itinsinuates that they cannot be
trusted, which is something thatwe don't want to do, especially
to a physician. So insinuationanxiety is this fear of implying
(14:34):
anything negative to someone,especially when they're standing
right in front of you.
So doctors do have specializedknowledge. We can't all go to
medical school and have all theknowledge and the understanding
of that information. But somepatients have twenty years of
experience with their particularillness that the doctor, A,
might not be aware of, or reallyunderstand what is important to
(14:57):
them. And as we know, there'sdifferent types of there's
different ways to practicemedicine. Some people, some
patients will preferpaternalistic medicine, just
being told what to do, becausethat is their preference.
Others want shared decisionmaking. Others want a guide, a
coach, as in here are thedifferent options. So there is a
(15:19):
patient preference aspect ofthat. But what I think is really
interesting when there was thewhole movement about ten years
ago for patients to choosewisely, when there were various
medical interventions orprocedures that they encouraged
patients to question, such assurgery for lower back pain. How
can we actually expect patientsto do this when it's so
(15:42):
difficult to question thedoctor?
And why should the burden fallon the patient at this point? So
these are questions that I thinkare very important in medicine.
And I think it's also importantfor both doctors and patients to
understand some of thepsychological processes that go
on between that relationship,that interaction, when they're
(16:03):
being told, yes, you should havea CT scan, or you should have
this procedure, or you shouldhave surgery. How patients,
possible, so it's not like acrisis moment where you have to
make a decision on the spot,where honestly, you just have to
give your trust to the doctor inthose situations, unless you
really feel something is wrong.But in situations, can you take
(16:24):
what I call the power of thepause, which is not to decide
straight away?
Even if I had said, let me thinkabout it for a few minutes, I
might have made a differentdecision. But I was immediately
wheeled through to the scannerand left there. And it just
felt, oh, is too late now to sayno, the process is happening. So
just asking for a few minutes tothink about something or taking
(16:48):
a step back and thinking, isthis really the right thing for
me? What are the alternatives?
And if the doctor doesn't havetime to answer those questions,
maybe that is a time to step outand do some research on your
own. I've also found, and peoplemight relate to this, that it's
far easier for me to ask for asecond opinion when it's for my
(17:09):
child than it is for myself. Andthis is really about how do we
connect with our responsibility,because sometimes we are willing
to give away our agency whenit's about ourselves. But if
it's about a loved one, then youknow I'm responsible here. I
really have to make sure this isthe right thing.
(17:30):
So if we can lean into thosesituations that this is what we
would advise a loved one, orthis is what we would want, then
we should also advocate forourselves in the same way.
Daniel Williams (17:41):
Right. What's going on psychologically within
us where we are very protectiveof those we love? And then
ourself, we go, yeah, sure, I'llgo right along with you. Why do
we not protect ourselves in thesame way?
Dr. Sunita Sah (17:55):
Because it's really hard. If you have been
socialized to be compliant, itbecomes almost our default
response to say yes and becompliant. And we start equating
being compliant with being goodand defiance with being And in
that situation, the next time Iwas called to have an
unnecessary scan, I did say nobecause I had thought about it.
(18:18):
I'd visualized what I wanted tosay. I practiced it.
I tried to change those neuralpathways of just my automatic
yes. And even with that, I feltlike I was being the difficult
patient, not going along withhow the clinic is running or
what they recommend. And we wantto avoid those types of things.
But if you are showing thatyou're connecting with your
(18:39):
responsibility for a loved oneand a child, it's not seen as a
negative thing. It's seen aslike you want to do the right
thing, and of course you'reconcerned about it.
And so we process all thesethings in a particular way of,
here I know my responsibility isfor a loved one, but can we
connect with that responsibilityfor ourselves? Who exactly are
(19:01):
we responsible for? Is it justour loved ones? Is it for
ourselves? Is it for acommunity?
And really for me as a physicianin those situations, it's all of
those things. Because I am aphysician, and I do believe in
the general principles ofmedical ethics. And maybe the
(19:22):
medical system doesn't changewhen I say no, but I did have an
experience a year later where Idecided to say no to an x-ray
that came before I saw thedoctor, and not have an
investigation before I've seenthe doctor. And when I told a
few people about this, they werelike, Oh, you should write that
up. And in the end, I did writeit up for JAMA Internal
(19:43):
Medicine, and that flooded myinbox with so many emails.
And some were like, You'reabsolutely right. Others were,
This is the most efficient wayto run a clinic, and I'm more
interested in quality of carerather than efficiency of care.
I know both are important, butif one is going to trump the
other, it should be the qualityof care. And others saying,
(20:06):
well, the system has to changebefore we do. And even if
rejecting something doesn'tchange the doctor's behavior or
how they run a clinic, ifsomebody else was to do the same
thing, maybe they would thinktwice.
So it does start off withindividual actions that can
(20:26):
eventually make a difference. Ithas a ripple effect.
Daniel Williams (20:29):
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 Iheard you correctly, there are
quite a few physicians in thecourse,
Dr. Sunita Sah (20:42):
is that That's correct.
Daniel Williams (20:43):
How has that helped you inform your research,
your thoughts on this act ofdefiance, so to speak? And then
what have they learned from you?Is there anything you can share,
an anecdote or anything you'velearned from that interaction
with a class of many of thembeing physicians?
Dr. Sunita Sah (21:07):
Yeah, about 50% of the class are physicians that
have been out of medical schoolfor about ten years. And they
come and they get a dual degree,both from the business school
and the medical school. So it'sa wonderful program. I love
teaching those students, andthey're so keen to learn. When I
(21:29):
teach healthcare leadership, wecover many aspects, including
values, which is reallyimportant.
Because a lot of them areconnected with their values due
to the work that they do, andit's usually due to an early
experience in their lives, inyoung adulthood or even in
childhood. And they have thesevery strong values. But often
(21:53):
what I've seen in my research aswell in the class is that how we
think we behave in a certainsituation is quite different
from how we actually behave. Sowe think we're going to do the
right thing, but when we're in aparticular situation, we freeze,
or we're uncertain, and we don'tconnect with our values. So
(22:14):
there have been some horrificstories that I've heard in the
classroom, of course, especiallyduring the pandemic.
Some of the students found itvery difficult to talk about.
They were first line in theemergency rooms during the
pandemic in New York City. Andthey found it very difficult to
talk about for a few years afterthat. And we did have some
(22:35):
harrowing cases within their ownclassroom and things that were
happening. And this aspect ofhow do we speak up in these
situations that are reallycritical and really important
became the focus of one of ourclass discussions.
So if you think about one of thereasons why I think this is so
(22:58):
important to study is when Istarted delving into it, I found
that there was one study thatfound that nine out of ten
healthcare workers on average,most of them nurses, did not
feel comfortable speaking upwhen they see a colleague or a
physician making an error. Sothis is the dangers of just
going along with things, notspeaking up, just swallowing how
(23:20):
we feel, and basically being socompliant. It really made me
start to think, is it sometimesbad to be so good, to be so
polite, so compliant, soagreeable? And what do we
actually sacrifice bydisregarding our values so
often?
Daniel Williams (23:38):
Okay. Thank you so much for that. Before we sign
off, have another question. Youhave a term in the book called
false defiance. Explain that tous, because I was trying to get
a handle on that.
What can you say about falsedefiance?
Dr. Sunita Sah (23:54):
So if we think about what defiance actually is,
which we need those fiveelements, the same elements that
we need for consent. Falsedefiance is something that looks
like defiance on the surface,but it's really not. It's done
for performative reasons orother reasons. So I have a
(24:15):
teenage son, and he often doesthe exact opposite. Or he at
least went through a phase ofdoing the exact opposite of what
I asked him to do.
So it was oppositional. And Ithought it was really
fascinating because what thatreally shows, if somebody does
the exact opposite of what youask them to do, it looks like
(24:37):
defiance. But he is listening sointently to what I want, to be
able to do the exact opposite.It's totally reliant on me. He's
relying on me.
So this is false defiance. Itlooks like defiance, but it's
not coming from an internalconsideration of our deeply held
values. Again, it's an externalforce like compliance. So like
(25:00):
compliance, false defiance isreally that type of following
somebody else's preferences,even if it's doing it in the
opposite direction. And we seethis also play out on social
media, that people will saythings just to be controversial
or to get lots of likes.
It's very performative. It's notdone because of a deeply held
(25:21):
value. And sometimes we can getcaught up in that. We can go to
a march or a protest justbecause all our friends are,
rather than the fact that weactually believe in a particular
cause. So we do need to becareful not to fall into the
trap of false defiance.
Daniel Williams (25:36):
Yeah. Last question then. Let's talk about
real defiance. You usehistorical figures, Rosa Parks,
Colin Kaepernick, and others inyour book. They did have
convictions.
They did stand by particularvalues that they had. Talk about
how medical practiceprofessionals and leaders can
(26:00):
learn from those historicalfigures and integrate that into
their own lives and have theirown acts of defiance, so to
speak.
Dr. Sunita Sah (26:08):
And I think this is one of the things that we
think about when we think aboutdefiance, is Rosa Parks' famous
No on the bus. I'm not going tomove for a white passenger. And
we often think of defiance asbeing negative, loud, angry, or
superhuman and heroic, like RosaParks and Colin Copernic. But it
(26:30):
doesn't have to be. If we thinkabout Rosa Parks' No on the bus,
it was preceded by hundreds ofmoments of compliance.
There were many times shecomplied with segregation laws
on the bus. That time shedecided not to. She connected
with her values for equality anddecided this was the time. So
there's two questions that Ibelieve that in my research that
(26:54):
I've seen in hospitals as wellfrom nurses and nurse managers,
two questions that nurses askthemselves about whether to
speak up or not. And the twoquestions are, is it safe and
will it be effective?
So they do talk about safety,which could be psychological
safety, but also what would bethe impact on my job if I
reported this error or how wouldI be treated? And so there is
(27:17):
that element of safety. But alsoI heard, I'm not scared about
speaking up, but nothing everchanges. I've spoken up so many
times, but this still happens.And so they give up hope in
speaking up.
If we go back to Rosa Parks onthe bus, was it safe and was it
effective for her to speak up?Well, it's never 100% Defiance
(27:39):
has some element of risk to it.And for Rosa Parks, it was not
safe at all. She was living in atime where she received death
threats from her defiance inthis situation. So it's very
individual choice as to how weassess safety and whether it's
going to be effective or not.
Colm Copernic didn't knowwhether it's going to be
(28:01):
effective if he sat down or ifhe took a knee. But sometimes we
just stand or we sit or we kneelbased on our principles rather
than whether it's going to beeffective or not. But both of
those actions had a rippleeffect and it was important. So
the thing to take away here isreally understanding who you
(28:23):
are, what your values are andwhat you stand for, and being
able to connect with those. Andthen you make your own judgment
of your, so your defiancecalculus in a way of what do you
need?
Because the question we shouldbe asking, is it safe enough? Is
it effective enough? Rather thanis it safe or is it effective?
Daniel Williams (28:42):
Right. Last thing I'm gonna add then,
everybody, I had the opportunityto both read and listen to Defy
over the past weekend. And,Sunita, you do the audio. You
are the narrator of the book. Ido wanna ask you.
I've mentioned that to youoffline, but what was that
(29:03):
experience like? You've donesome acts of defiance and
stepping out. That seems like anew enterprise for you. What was
that like?
Dr. Sunita Sah (29:13):
So it was certainly an amazing experience
in a way. It was something newfor me. I had an amazing
director who would speak to meover the headphones. And she
guided me a lot, so that wasreally important to have. But I
felt it was important for me toread the words.
I thought readers would be ableto connect more with the message
(29:33):
if it was the author doing it. Iam not a professional audio
reader, so it was an experiencebut a great one to have. And
certainly I've heard lots ofgreat things from people who
have listened to the audio, andat least one close friend saying
that she's listened to it fourtimes now. So that really
(29:57):
touches me and it means a lot.That in any way that you prefer
to receive information, whetherit's audio or reading, the
important thing is that I wantto give people the tools to make
Defiance accessible to everyone.
Because I think it's a reallynecessary skill set for us to
have.
Daniel Williams (30:14):
Yeah. I've talked about this on the podcast
before. We have a book club thatI moderate at MGMA. It's
available to MGMA members. Wehave to fi on the list for later
this So anybody listening,please be on the lookout for
that or send me an email, get intouch with me, and we'll get you
(30:36):
on that book club as well.
And I will concur with what yourfriend said. You I consume a lot
of books, both in print and Ilisten to them as well. And you
did an amazing job because Ireally do grade not only what
are the words that are on thepage or that you hear being
said, but also the voice of thenarrator. And you did great job.
(31:01):
I mean that was reallyimpressive.
Dr. Sunita Sah (31:03):
Thank you so much. Really appreciate those
words. Thank you.
Daniel Williams (31:06):
Yeah. Well, doctor Sunitas, I do wanna thank
you for joining us on the MGMApodcast. I'm so glad that I I I
think I learned about you onLinkedIn months ago. I think the
book was either had just comeout or was coming out. And
somehow one of the MGMA membersor someone else in my healthcare
(31:28):
sphere had posted somethingabout it.
I said, I've got to get you onthe show. And so I'm so glad
you're here. Thank you forjoining us.
Dr. Sunita Sah (31:34):
Thank you very much. It was wonderful to speak
with you.
Daniel Williams (31:37):
Yeah. So that is going to do it for this
episode of MGMA Insightspodcast, everyone. I'm going to
put direct links to both Doctor.Sa's website as well as places
where you can access andpurchase the book as well. So
until then, thank you all forbeing MGMA podcast listeners.
Today we have Doctor Sunita Sa. Doctor. Sa, I
want to get this right, is atenured professor and
organizational psychologist atCornell University and also is
the author of a new book, Defy.
We're gonna talk a lot aboutDefy as well as Doctor Sa's
background. Doctor Sa, welcometo the show.
Dr. Sunita Sah (01:24):
It's wonderful to be here, and please do call
me Sunita.
Daniel Williams (01:28):
Oh, Sunita. Okay. Well, great having you
here, Sunita. And I see, wellrepresented behind you, copies
of Defy. I was telling youoffline.
I had so much fun reading thebook, learning about it. We're
gonna talk about this book. Butfirst, you have a little secret
you divulge in the book that youare a big fan of the cure.
(01:51):
That's right. Yes.
I'm a child of the eighties.Well, guess a child. I went to
high school and college duringthe eighties. And so another fan
of the cure. Tell me about thatlove for the cure and how that
is defiant moment in your life.
Dr. Sunita Sah (02:08):
Well, my parents hated the cure. But I love them.
And I grew up, as I describe inDeFi, with a master class in
compliance. Even my name,Sunita, I remember asking my dad
at one point, what does thatmean? And he was like, Sunita in
Sanskrit means good.
(02:30):
And mostly I lived up to that.So I did How do you interpret
the word good as a child?
Daniel Williams (02:36):
I
Dr. Sunita Sah (02:37):
did as I was told. I was polite. I went to
school on time, I did all myhomework as expected, I even had
my hair cut the way my parentsinsisted. But yes, I did love
The Cure. When I got to aboutthe age of 16, I went to see The
Cure three times.
It was my favorite band, and Iremember actually backcombing my
(03:00):
hair the way that Robert Smithdoes, and that did have my mum
running down the driveway afterme with hairbrush in hand
thinking I'd forgotten to dosomething.
Daniel Williams (03:12):
And just to elaborate on that, everyone. So,
Sunita, tell us a little bitabout that. You grew up you're
in America. Now you're atCornell, but you grew up in
London, is that correct? Tell usa little bit about that
background.
Dr. Sunita Sah (03:24):
Sure. I grew up in Yorkshire in The UK, which is
in the North Of England. Didmove to London and spent ten
years there before I moved toThe US. But yes, I'm from the
North, and my parents emigratedthere. I grew up with learnings
of these messages from, not justfrom parents, but from teachers
(03:46):
and communities, like to begood, to obey, to fit in.
And we often teach our childrenthese messages. And that
actually led to my first careeras well. In The UK, Medicine is
a combined undergraduate andgraduate degree. I had the
grades and I was told medicineis the best thing you can do. So
even though I was a little bitunsure about the clinical aspect
(04:09):
of medicine, I'm a bitsqueamish, but I ended up going
to medical school and finishingmedical school and working as a
physician, which was reallybased on expectations, that
first career.
So it took a couple of steps toget to where I am now, working
as a professor at CornellUniversity, and delving into
(04:30):
this research on advice, why wetake bad advice, and compliance
and defiance.
Daniel Williams (04:37):
Right. And so in addition to talking about
your love for the cure there,you have a wonderful illustrated
story at the beginning whereyou're in a medical setting, you
have clinicians talking to youabout taking some tests. I don't
want to get anything wrong fromthere. So walk us through what
(04:58):
happened and what went throughyour mindset, to use that as an
illustration in this book?
Dr. Sunita Sah (05:04):
I think it was a couple of years after I had
moved to The US. And I wasexperiencing some chest pain.
And it was a kind of pain that Ihad not experienced before. So I
was a little bit worried aboutit. And I ended up going to the
emergency room and I was whiskedthrough triage.
It went so fast. And there wasloads of tests being done,
(05:27):
including an electrocardiogram,which was fine. It turned out to
be fine. That was the main thingthat I was concerned about,
anything sort of going on withmy heart. And the pain was
actually subsiding.
So I was thinking I would bedischarged. And then I was told,
well, actually, before we letyou go, we should do a CT scan.
(05:50):
And I was like, why? Why do Ineed a CT scan? Like this
contrast CT scan, which hasquite a bit of radiation, about
70 times more on average than anx-ray, but still is small, but
it's still a significant amount.
And they said, We want to makesure that you don't have a
pulmonary embolism. Now, thistype of embolism is a blood clot
(06:13):
in the lungs. I used to work inwhat we call respiratory
medicine in The UK. I think it'spulmonary here. And it has a
particular type of pain, what wecall pleuritic chest pain.
So it catches your breath whenyou breathe in, when you breathe
out, it's very sharp, stabbing.I was not having that type of
pain. So I was pretty certain Idid not have a pulmonary
(06:34):
embolism. And so why would Iexpose myself to ionizing
radiation if I didn't need it? Ishould have said no to that
scan, and I couldn't do it atall.
And the only reason I went alongand had it was because the
doctor told me so. And the wholetime that the scanner was going,
I was so perplexed. Why couldn'tI just say, I'd rather not have
(06:58):
the scan? And I just didn't wantto make a fuss. I didn't want to
be the difficult patient.
I didn't want to be questioningthe doctor's opinion. And after
I walked out of that hospital,and of course the scan showed my
very healthy lungs, I justthought, why did that happen?
Why couldn't I say no in anenvironment where informed
(07:21):
consent is pretty high on theirlist of priorities? Why did I
feel I couldn't say no in thatsituation? And I was really
fascinated by that.
And some of my research wasalready looking at that type of
compliance in medicalenvironments. It spread to other
types of environments too. But Ireally was fascinated by how
(07:43):
difficult it was for me to sayno in that situation and what we
can do to help not just patientschoose correctly, but all of us
in everyday decisions that wemake in life.
Daniel Williams (07:53):
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 tobe political about it, but there
are a lot of challenges going onright now in health care. We saw
it, you know, do we mask duringCOVID? Do we not mask? Do we get
(08:14):
a shot?
Do we not get a shot? Or do wetake other types of remedies, so
to speak, to protect ourselvesor others? You had a particular
experienced viewpoint of whatwas going on, you being a
physician, you knew a little bitmore than or a lot more than
(08:35):
your average person would, whereis it where we are really
following our compass thereversus having an informed
background versus, oh, this isan expert. They tell me to do
this. I'm going to do exactlywhat they say no matter what
they say.
And I am embarrassed almost tosay I don't recall if you touch
(08:59):
on that specific aspect in thebook, but I would love to know
your thoughts on that aspectbecause it is a real challenge
right now about do we questionauthority 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 (09:15):
and that's a great question. And it's a
discussion that I have a lotwith my health care leadership
class with my students. And halfthe class are senior physicians,
the other half work inhealthcare too. And medicine, we
have a high level of trust inour doctors, and it would be a
shame for that trust todisappear. But sometimes, do
(09:38):
they know exactly what's rightfor a particular individual?
Sometimes it is good toquestion, and I'll tell you the
situations where I think that'sthe right thing to do. So I
differentiate in the bookbetween compliance and consent.
So compliance is something thatyou slide into, externally
(10:02):
imposed. So somebody tellingyou, giving you a suggestion, an
order, or even society'sexpectations. You should do
medicine.
It's the best thing you can do.That is compliance. Now, if we
think about consent, we canactually take the definition of
informed consent in medicine andapply it to the decision that I
(10:22):
was making and that other peoplemake. And that requires five
elements. We often conflate bothcompliance and consent, but they
are fundamentally different.
So for consent, or what I callyour true yes, you need five
elements. So you need capacity.Physicians will assess patients
for their mental capacity, thatthey're not too sick, they're
(10:44):
not under the influence of drugsor alcohol. So that's the first
one. The second one isknowledge.
You need information about thatdecision that you're going to
make. But it's not enough justto have the information. You
need to have a fullunderstanding of that
information. So a real grasp ofthe facts, the risks, the
(11:05):
benefits, the alternatives, andthat includes the source, the
accuracy of the information,which I think is one of the
difficult things that we'refacing in today's age. It's
like, what is this information?
Is it accurate? How much do weEspecially with the amount of
misinformation that's aroundthese So we have capacity,
(11:26):
knowledge, understanding. Thefourth element is the freedom to
say no, because if you don'thave the freedom to say no, then
it's merely compliance, it's notconsent. And if those four
elements are present, then youcan give your authorization,
which is your thoroughlyconsidered authorization of your
(11:46):
deeply held values. So if youwant to say yes, that's your
true yes, that's consent.
If you want to say no, that'syour informed refusal or
defiance. And in that particularsituation with a CT scan, I did
have the knowledge andunderstanding. So I could give a
true yes or a true no. I didhave the freedom to say no, like
(12:07):
nothing would have happened.This isn't exactly the type of
environment where you ask forpatient autonomy.
And I could have said no, andyet I didn't. And that is what
is so fascinating about this, iswhen all the elements for
consent are present, why do wesay yes when we actually mean
(12:28):
no?
Daniel Williams (12:29):
Right. Let's look at it again from the
healthcare side of it. Patientsare in situations where the
clinician is telling them thisis what is. And as you say in
your book, often the patientsdon't question it. Let's not
even think about question may ormay not be the right way to even
(12:52):
say it, but to at least have aconversation about it like, is
this right for me?
Can I consult with my family?Can I talk to someone else just
so it could be a I don't mean ahigh pressure situation like
this is a used car lot, nothingagainst used cars, but I mean,
(13:15):
where they won't let you off thelot, 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 itmight be a very high pressure
situation where something needsto be done, a really difficult
decision might need to be made.
(13:36):
So in that scenario, what canthe patient do to get the right
kind of information they need inthat moment to have the
conversation they need to havewith that medical staff there or
with other people that aretrusted within their circle?
Dr. Sunita Sah (13:52):
Yeah, so in these situations, they can be
high precious situations. Ofpatients have spoken to me about
how they feel that theirphysician is always so busy, and
they say something and theydon't feel that they have the
room to question. And this goeswith one of the psychological
processes that I've discoveredin my research that I call
(14:12):
insinuation anxiety. Whensomebody is supposed to have
your best interests at heartlike doctors, it is very
difficult to say no because itinsinuates that they cannot be
trusted, which is something thatwe don't want to do, especially
to a physician. So insinuationanxiety is this fear of implying
(14:34):
anything negative to someone,especially when they're standing
right in front of you.
So doctors do have specializedknowledge. We can't all go to
medical school and have all theknowledge and the understanding
of that information. But somepatients have twenty years of
experience with their particularillness that the doctor, A,
might not be aware of, or reallyunderstand what is important to
(14:57):
them. And as we know, there'sdifferent types of there's
different ways to practicemedicine. Some people, some
patients will preferpaternalistic medicine, just
being told what to do, becausethat is their preference.
Others want shared decisionmaking. Others want a guide, a
coach, as in here are thedifferent options. So there is a
(15:19):
patient preference aspect ofthat. But what I think is really
interesting when there was thewhole movement about ten years
ago for patients to choosewisely, when there were various
medical interventions orprocedures that they encouraged
patients to question, such assurgery for lower back pain. How
can we actually expect patientsto do this when it's so
(15:42):
difficult to question thedoctor?
And why should the burden fallon the patient at this point? So
these are questions that I thinkare very important in medicine.
And I think it's also importantfor both doctors and patients to
understand some of thepsychological processes that go
on between that relationship,that interaction, when they're
(16:03):
being told, yes, you should havea CT scan, or you should have
this procedure, or you shouldhave surgery. How patients,
possible, so it's not like acrisis moment where you have to
make a decision on the spot,where honestly, you just have to
give your trust to the doctor inthose situations, unless you
really feel something is wrong.But in situations, can you take
(16:24):
what I call the power of thepause, which is not to decide
straight away?
Even if I had said, let me thinkabout it for a few minutes, I
might have made a differentdecision. But I was immediately
wheeled through to the scannerand left there. And it just
felt, oh, is too late now to sayno, the process is happening. So
just asking for a few minutes tothink about something or taking
(16:48):
a step back and thinking, isthis really the right thing for
me? What are the alternatives?
And if the doctor doesn't havetime to answer those questions,
maybe that is a time to step outand do some research on your
own. I've also found, and peoplemight relate to this, that it's
far easier for me to ask for asecond opinion when it's for my
(17:09):
child than it is for myself. Andthis is really about how do we
connect with our responsibility,because sometimes we are willing
to give away our agency whenit's about ourselves. But if
it's about a loved one, then youknow I'm responsible here. I
really have to make sure this isthe right thing.
(17:30):
So if we can lean into thosesituations that this is what we
would advise a loved one, orthis is what we would want, then
we should also advocate forourselves in the same way.
Daniel Williams (17:41):
Right. What's going on psychologically within
us where we are very protectiveof those we love? And then
ourself, we go, yeah, sure, I'llgo right along with you. Why do
we not protect ourselves in thesame way?
Dr. Sunita Sah (17:55):
Because it's really hard. If you have been
socialized to be compliant, itbecomes almost our default
response to say yes and becompliant. And we start equating
being compliant with being goodand defiance with being And in
that situation, the next time Iwas called to have an
unnecessary scan, I did say nobecause I had thought about it.
(18:18):
I'd visualized what I wanted tosay. I practiced it.
I tried to change those neuralpathways of just my automatic
yes. And even with that, I feltlike I was being the difficult
patient, not going along withhow the clinic is running or
what they recommend. And we wantto avoid those types of things.
But if you are showing thatyou're connecting with your
(18:39):
responsibility for a loved oneand a child, it's not seen as a
negative thing. It's seen aslike you want to do the right
thing, and of course you'reconcerned about it.
And so we process all thesethings in a particular way of,
here I know my responsibility isfor a loved one, but can we
connect with that responsibilityfor ourselves? Who exactly are
(19:01):
we responsible for? Is it justour loved ones? Is it for
ourselves? Is it for acommunity?
And really for me as a physicianin those situations, it's all of
those things. Because I am aphysician, and I do believe in
the general principles ofmedical ethics. And maybe the
(19:22):
medical system doesn't changewhen I say no, but I did have an
experience a year later where Idecided to say no to an x-ray
that came before I saw thedoctor, and not have an
investigation before I've seenthe doctor. And when I told a
few people about this, they werelike, Oh, you should write that
up. And in the end, I did writeit up for JAMA Internal
(19:43):
Medicine, and that flooded myinbox with so many emails.
And some were like, You'reabsolutely right. Others were,
This is the most efficient wayto run a clinic, and I'm more
interested in quality of carerather than efficiency of care.
I know both are important, butif one is going to trump the
other, it should be the qualityof care. And others saying,
(20:06):
well, the system has to changebefore we do. And even if
rejecting something doesn'tchange the doctor's behavior or
how they run a clinic, ifsomebody else was to do the same
thing, maybe they would thinktwice.
So it does start off withindividual actions that can
(20:26):
eventually make a difference. Ithas a ripple effect.
Daniel Williams (20:29):
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 Iheard you correctly, there are
quite a few physicians in thecourse,
Dr. Sunita Sah (20:42):
is that That's correct.
Daniel Williams (20:43):
How has that helped you inform your research,
your thoughts on this act ofdefiance, so to speak? And then
what have they learned from you?Is there anything you can share,
an anecdote or anything you'velearned from that interaction
with a class of many of thembeing physicians?
Dr. Sunita Sah (21:07):
Yeah, about 50% of the class are physicians that
have been out of medical schoolfor about ten years. And they
come and they get a dual degree,both from the business school
and the medical school. So it'sa wonderful program. I love
teaching those students, andthey're so keen to learn. When I
(21:29):
teach healthcare leadership, wecover many aspects, including
values, which is reallyimportant.
Because a lot of them areconnected with their values due
to the work that they do, andit's usually due to an early
experience in their lives, inyoung adulthood or even in
childhood. And they have thesevery strong values. But often
(21:53):
what I've seen in my research aswell in the class is that how we
think we behave in a certainsituation is quite different
from how we actually behave. Sowe think we're going to do the
right thing, but when we're in aparticular situation, we freeze,
or we're uncertain, and we don'tconnect with our values. So
(22:14):
there have been some horrificstories that I've heard in the
classroom, of course, especiallyduring the pandemic.
Some of the students found itvery difficult to talk about.
They were first line in theemergency rooms during the
pandemic in New York City. Andthey found it very difficult to
talk about for a few years afterthat. And we did have some
(22:35):
harrowing cases within their ownclassroom and things that were
happening. And this aspect ofhow do we speak up in these
situations that are reallycritical and really important
became the focus of one of ourclass discussions.
So if you think about one of thereasons why I think this is so
(22:58):
important to study is when Istarted delving into it, I found
that there was one study thatfound that nine out of ten
healthcare workers on average,most of them nurses, did not
feel comfortable speaking upwhen they see a colleague or a
physician making an error. Sothis is the dangers of just
going along with things, notspeaking up, just swallowing how
(23:20):
we feel, and basically being socompliant. It really made me
start to think, is it sometimesbad to be so good, to be so
polite, so compliant, soagreeable? And what do we
actually sacrifice bydisregarding our values so
often?
Daniel Williams (23:38):
Okay. Thank you so much for that. Before we sign
off, have another question. Youhave a term in the book called
false defiance. Explain that tous, because I was trying to get
a handle on that.
What can you say about falsedefiance?
Dr. Sunita Sah (23:54):
So if we think about what defiance actually is,
which we need those fiveelements, the same elements that
we need for consent. Falsedefiance is something that looks
like defiance on the surface,but it's really not. It's done
for performative reasons orother reasons. So I have a
(24:15):
teenage son, and he often doesthe exact opposite. Or he at
least went through a phase ofdoing the exact opposite of what
I asked him to do.
So it was oppositional. And Ithought it was really
fascinating because what thatreally shows, if somebody does
the exact opposite of what youask them to do, it looks like
(24:37):
defiance. But he is listening sointently to what I want, to be
able to do the exact opposite.It's totally reliant on me. He's
relying on me.
So this is false defiance. Itlooks like defiance, but it's
not coming from an internalconsideration of our deeply held
values. Again, it's an externalforce like compliance. So like
(25:00):
compliance, false defiance isreally that type of following
somebody else's preferences,even if it's doing it in the
opposite direction. And we seethis also play out on social
media, that people will saythings just to be controversial
or to get lots of likes.
It's very performative. It's notdone because of a deeply held
(25:21):
value. And sometimes we can getcaught up in that. We can go to
a march or a protest justbecause all our friends are,
rather than the fact that weactually believe in a particular
cause. So we do need to becareful not to fall into the
trap of false defiance.
Daniel Williams (25:36):
Yeah. Last question then. Let's talk about
real defiance. You usehistorical figures, Rosa Parks,
Colin Kaepernick, and others inyour book. They did have
convictions.
They did stand by particularvalues that they had. Talk about
how medical practiceprofessionals and leaders can
(26:00):
learn from those historicalfigures and integrate that into
their own lives and have theirown acts of defiance, so to
speak.
Dr. Sunita Sah (26:08):
And I think this is one of the things that we
think about when we think aboutdefiance, is Rosa Parks' famous
No on the bus. I'm not going tomove for a white passenger. And
we often think of defiance asbeing negative, loud, angry, or
superhuman and heroic, like RosaParks and Colin Copernic. But it
(26:30):
doesn't have to be. If we thinkabout Rosa Parks' No on the bus,
it was preceded by hundreds ofmoments of compliance.
There were many times shecomplied with segregation laws
on the bus. That time shedecided not to. She connected
with her values for equality anddecided this was the time. So
there's two questions that Ibelieve that in my research that
(26:54):
I've seen in hospitals as wellfrom nurses and nurse managers,
two questions that nurses askthemselves about whether to
speak up or not. And the twoquestions are, is it safe and
will it be effective?
So they do talk about safety,which could be psychological
safety, but also what would bethe impact on my job if I
reported this error or how wouldI be treated? And so there is
(27:17):
that element of safety. But alsoI heard, I'm not scared about
speaking up, but nothing everchanges. I've spoken up so many
times, but this still happens.And so they give up hope in
speaking up.
If we go back to Rosa Parks onthe bus, was it safe and was it
effective for her to speak up?Well, it's never 100% Defiance
(27:39):
has some element of risk to it.And for Rosa Parks, it was not
safe at all. She was living in atime where she received death
threats from her defiance inthis situation. So it's very
individual choice as to how weassess safety and whether it's
going to be effective or not.
Colm Copernic didn't knowwhether it's going to be
(28:01):
effective if he sat down or ifhe took a knee. But sometimes we
just stand or we sit or we kneelbased on our principles rather
than whether it's going to beeffective or not. But both of
those actions had a rippleeffect and it was important. So
the thing to take away here isreally understanding who you
(28:23):
are, what your values are andwhat you stand for, and being
able to connect with those. Andthen you make your own judgment
of your, so your defiancecalculus in a way of what do you
need?
Because the question we shouldbe asking, is it safe enough? Is
it effective enough? Rather thanis it safe or is it effective?
Daniel Williams (28:42):
Right. Last thing I'm gonna add then,
everybody, I had the opportunityto both read and listen to Defy
over the past weekend. And,Sunita, you do the audio. You
are the narrator of the book. Ido wanna ask you.
I've mentioned that to youoffline, but what was that
(29:03):
experience like? You've donesome acts of defiance and
stepping out. That seems like anew enterprise for you. What was
that like?
Dr. Sunita Sah (29:13):
So it was certainly an amazing experience
in a way. It was something newfor me. I had an amazing
director who would speak to meover the headphones. And she
guided me a lot, so that wasreally important to have. But I
felt it was important for me toread the words.
I thought readers would be ableto connect more with the message
(29:33):
if it was the author doing it. Iam not a professional audio
reader, so it was an experiencebut a great one to have. And
certainly I've heard lots ofgreat things from people who
have listened to the audio, andat least one close friend saying
that she's listened to it fourtimes now. So that really
(29:57):
touches me and it means a lot.That in any way that you prefer
to receive information, whetherit's audio or reading, the
important thing is that I wantto give people the tools to make
Defiance accessible to everyone.
Because I think it's a reallynecessary skill set for us to
have.
Daniel Williams (30:14):
Yeah. I've talked about this on the podcast
before. We have a book club thatI moderate at MGMA. It's
available to MGMA members. Wehave to fi on the list for later
this So anybody listening,please be on the lookout for
that or send me an email, get intouch with me, and we'll get you
(30:36):
on that book club as well.
And I will concur with what yourfriend said. You I consume a lot
of books, both in print and Ilisten to them as well. And you
did an amazing job because Ireally do grade not only what
are the words that are on thepage or that you hear being
said, but also the voice of thenarrator. And you did great job.
(31:01):
I mean that was reallyimpressive.
Dr. Sunita Sah (31:03):
Thank you so much. Really appreciate those
words. Thank you.
Daniel Williams (31:06):
Yeah. Well, doctor Sunitas, I do wanna thank
you for joining us on the MGMApodcast. I'm so glad that I I I
think I learned about you onLinkedIn months ago. I think the
book was either had just comeout or was coming out. And
somehow one of the MGMA membersor someone else in my healthcare
(31:28):
sphere had posted somethingabout it.
I said, I've got to get you onthe show. And so I'm so glad
you're here. Thank you forjoining us.
Dr. Sunita Sah (31:34):
Thank you very much. It was wonderful to speak
with you.
Daniel Williams (31:37):
Yeah. So that is going to do it for this
episode of MGMA Insightspodcast, everyone. I'm going to
put direct links to both Doctor.Sa's website as well as places
where you can access andpurchase the book as well. So
until then, thank you all forbeing MGMA podcast listeners.
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