In medical settings, patients often agree to procedures or advice they don’t fully understand or support. Dr. Sunita Sah, physician and organizational psychologist at Cornell University, believes this behavior is less about medical necessity and more about psychology. On this episode of the MGMA Insights podcast, Dr. Sah explains why people follow expert recommendations even when they feel uncertain.
Recalling her experience with an unnecessary CT scan, Dr. Sah explains she only went along with the procedure because the doctor told her so. Her decision wasn’t based on clinical need—her EKG was normal, the pain was subsiding—but on the subtle pressures of the medical setting. “I just didn’t want to make a fuss,” she says. “I didn’t want to be the difficult patient.”
Key Distinction: Compliance vs. Consent
Dr. Sah makes a clear distinction between true informed consent and what she calls “compliance.” According to her, true consent requires five elements:
- Capacity
- Knowledge
- Understanding
- Freedom to say no
- Authorization based on personal values
“When all the elements for consent are present, why do we say yes when we actually mean no?” she asks. This question forms the basis of her book, Defy, and her broader research. “If you don’t have the freedom to say no, then it’s merely compliance—it’s not consent.”
Psychological Pressure in Patient Care
One of the factors that keeps patients from voicing concerns is what Dr. Sah calls “insinuation anxiety.” This is the fear of suggesting that a doctor may be wrong or untrustworthy. “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,” she notes.
This kind of anxiety is reinforced by time constraints, uncertainty, and the perception that pushing back might disrupt care or signal disrespect.
Dr. Sah also points out that people are often more assertive when making decisions on behalf of others. “It’s far easier for me to ask for a second opinion when it’s for my child than it is for myself,” she highlights. “Sometimes we’re willing to give away our agency when it’s about ourselves.”
Organizational Implications for Healthcare Leaders
Dr. Sah teaches a healthcare leadership course at Cornell University, where many of her students are physicians with nearly a decade of clinical experience. In her teaching, she sees how misalignment between values and actions plays out in real-world cases.
“We think we’re going to do the right thing,” she says, “but when we’re in a particular situation, we freeze or we’re uncertain and we don’t connect with our values.”
She points to research showing that most nurses do not feel comfortable speaking up when they see an error. “Nine out of 10 healthcare workers, most of them nurses, did not feel comfortable speaking up when they saw a colleague or physician making an error,” she emphasizes.
This silence has consequences—for patients and for the culture of a practice.
Defiance Isn’t Always What It Seems
Dr. Sah differentiates between what she calls “true defiance” and “false defiance.” The former comes from values. The latter is reactive or performative.
“If somebody does the exact opposite of what you ask them to do, it looks like defiance,” she says, referencing her teenage son. False defiance, Dr. Sah says, is still rooted in external influence. “It’s not coming from an internal consideration of our deeply held values.
Speaking Up Starts with Values
Healthcare professionals often ask: Is it safe to speak up? Will it be effective? Dr. Sah argues that both are important, but shouldn’t be the only criteria.
“Defiance has some element of risk to it,” she says. “So we just stand or we sit or we kneel based on our principles rather than whether it’s going to be effective or not.”
She encourages healthcare leaders to create environments where both patients and staff feel permission to pause, ask questions, and connect with their values.
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:
Email us at dwilliams@mgma.com if you would like to appear on an episode. If you have a question about your practice that you would like us to answer, send an email to advisor@mgma.com. Don't forget to subscribe to our network wherever you get your podcasts.
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