The crucial personality characteristic that can save you from medical tragedy

After reading Gretchen Rubin’s book The Four Tendencies last year, which lays out a conceptual framework for how people tend to respond to both inner and outer expectations, I began asking clients to take the quiz that Rubin developed to help people identify their tendency, before their initial appointment with me.

I took this step because awareness of an individual’s tendency helps me to help them better – to gauge how much or how little information about their condition they prefer to receive; to tailor their treatment plans more precisely to their needs; to decide whether they require accountability, and if so, in what form; and to help them identify likely obstacles to implementation.

It’s also incredibly useful to my clients to understand their own tendency, and the tendency of their significant other, children and colleagues, in order

But a rather intriguing pattern began to emerge as new clients notified me of their Four Tendencies quiz results: despite Gretchen Rubin’s research indicating that 24% of people in the general population are Questioners, close to 90% of my clients fall into this tendency.

Questioners challenge all outer expectations – that is, anything that an authority figure (including a doctor or other health care provider) tells them to do, or that society, their family, or even their partner expects of them. However, they readily act on inner expectations – once something makes sense to them, they generally do it without much fuss.

When I discussed the overrepresentation of the Questioner tendency among my clients with my Questioner husband, he looked at me as if had just announced to him that I’d discovered the Earth was round.

“Well, of course you see more Questioners. What would you expect?”

What he meant was that in general, people who consult me have already seen doctors and other health practitioners, and they’re not satisfied with the information that they’ve received so far about either their condition or the best way to go about treating it. That’s why they turn up in my office.

And he was right, of course. As a fellow Questioner, he understands perfectly the drive that Questioners experience to get all their questions answered, all their doubts addressed, and all their concerns aired before they can move forward on a treatment plan.

The truth is, I LOVE working with Questioner clients, even though I’m not one myself*. Their obsessive drive to understand the nitty-gritty meshes beautifully with my nerdy fascination with all the details that other people find boring. And their willingness (in fact, urge) to challenge authority – including mine – keeps me at the top of my game, always querying my own assumptions and keeping abreast of the scientific research so that any explanation I give and anything I include in their treatment plan will stand up to the most rigorous fact-checking.

As a result of their sheer inability to take anything that anyone else says at face value, Questioners often avoid undertaking useless or harmful medical treatment that people without the Questioner ‘gene’ might get sucked into.

An article published in ProPublica, titled ‘When Evidence Says No, But Doctors Say Yes’ poignantly illustrates the point, relating the true stories of two middle-aged men who were both pressured to undergo a coronary angiogram, a procedure that was not indicated for either of them given their presenting symptoms.

One man began researching the risks and benefits of the procedure on his smartphone while in the waiting room, and what he found convinced him to decline the procedure and opt for a second, and then a third opinion. He undertook diet and lifestyle change and took some medication, and his issues resolved within a few months. My guess is he was a Questioner.

The other man agreed to coronary angiography and had a stent inserted in his artery (even though research shows clearly that stenting in non-acute cases like his offers no benefit to the patient whatsoever), and as a consequence, could not undergo a life-saving lung transplant and died an agonising death. Tragically for him, he was probably not a Questioner.

But those of us who don’t have the Questioner tendency aren’t doomed. We can consciously adopt the mindset that comes naturally to Questioners:

• Just because someone in authority tells me I should do something, that doesn’t mean I should. I’ll investigate it for myself, thank you very much.
• ‘That’s the way we’ve always done things’ is not a valid reason to do anything. Every rule or instruction should stand on its own merits and those who propound it should be willing to defend it rationally and not resort to the logical fallacy of ‘appeal to authority‘.
• Any doctrine or dogma is in need of urgent challenging and should be abandoned if the evidence doesn’t support it.
• There’s a better answer to any question I’m asking, and a better solution to any problem I’m facing, than the ones I’ve got so far, and it’s my job to find them.

And there’s no more important domain of life to apply Questioner thinking than our health and medical care decisions… because they can literally be matters of life and death.

The medical literature is replete with examples of widely-accepted medical practices that are not evidence-based. Here is a small sample:

• A 2012 study found that out of almost 6000 items listed on the Medicare Benefits Scheme (MBS), which specifies what doctors can provide to their private patients on a fee-for-service basis, and be reimbursed for by Medicare (which means you and I, the taxpayers), “only around 3% of these (accounting for about 1% of total MBS expenditure) have been formally assessed against contemporary evidence of safety, effectiveness and cost-effectiveness review”. That means that 97% of what your doctor does, including knee arthroscopy for osteoarthritis, x-rays and other imaging for low back pain, exercise electrocardiograms (‘stress tests’), liver function tests, radical prostatectomy and chlamydia screening, are not evidence-based. Good to know.
• A Cochrane Review published in 2019 found that general health checks, including annual ‘check-ups’ and the 45 Year Old Health Check introduced in Australia in 2006, are unlikely to be beneficial and may result in harm since so few of the screening tests employed are evidence-based. More specifically, they found that general health checks have little or no effect on either total mortality or cancer mortality (that is, they don’t reduce your risk of death overall, or specifically from cancer); and probably have little or no effect on your risk of having a heart attack or stroke or dying of cardiovascular causes. On the other hand, these useless checks put you at risk of overdiagnosis and overtreatment for conditions that you don’t actually have, or are better off not knowing about because they won’t kill you.
• A Cochrane review of treatment for high blood pressure in adults under 60, found that people with high blood pressure who were treated with antihypertensive medication experienced negligible benefits: their risk of death from any cause was 2.3% overall while those treated with placebo or not treated at all had a 2.4% risk; risk of suffering from or dying from heart disease was reduced from 4.1% with placebo/no treatment to 3.2% with treatment; and stroke risk was reduced from 1.3% with placebo/no treatment to 0.6% with treatment. Evidence for even these paltry risk reductions was rated by Cochrane as low quality, due to the high risk of bias in several of the trials included in the review.
• A systematic review of published cases identified six categories of
  negative consequences of ‘medical overuse’ (that is, inappropriate use of medical tests and treatment for patients – physical, psychological, social, financial, treatment burden, and dissatisfaction with health care. The authors of the review identified an “ongoing feedback loop” in which negative consequences resulting from overused services trigger the use of more services which then trigger further negative results which result in more downstream services, and so on. I have seen countless examples of this in my own practice; most recently,
• And, as mentioned above, coronary angiography and stenting does NOT reduce the risk of suffering or dying from a heart attack and should not be performed unless a patient is in the middle of having a heart attack.

Of course, you need to have good criteria for decision-making; some Questioners are prone to adopting ‘crackpot’ ideas about health and diet because of their innate distrust of authority, even though the weight of scientific evidence may actually support that authority’s advice.

I teach people how to access and understand medical literature, and how to grade the plethora of nutrition and health advice that litters the InterWebs, in my EmpowerEd membership program. To activate your free 1-month trial of EmpowerEd, which instantly unlocks all the benefits of membership including access to 2 video courses and hundreds of hours of webinars, head over here.

* FYI, I’m an Upholder – I readily meet both inner and outer expectations.