What’s Your Tendency?

by | Dec 16, 2021 | Entrepreneurship, Ownership

Understanding this one aspect of personality will help you relate to your patients and staff more effectively.

Over the summer, a friend and I were sharing what books we had recently read that we found interesting and impactful.  Knowing that I have a deep interest in leadership and personal development, my friend mentioned the book “The Four Tendencies” by Gretchen Rubin. As someone who is fascinated by human behavior (and patient behavior!) I immediately ordered the book and couldn’t wait to dive in.

The author wrote that we can gain insight into ourselves and other people by asking one simple question, “How do I respond to expectation?”  There are two types of expectations we face- outer expectations (work deadlines, meetings, gym classes) and inner expectations (resolutions, self driven workout goals).  How we respond to expectations puts us into one of four categories- Upholder, Questioner, Obliger, or Rebel. This is not a “personality” per se, but an aspect of personality: our typical response to expectations. 

No such thing as one-size-fits-all

Before beginning the book, there is a quiz to help you determine your tendency, and right away it was an “aha” moment into how I think and act.  What I enjoyed most about the book (other than identifying why I behave a certain way!) was it gave me insight into how I could work better with my staff and patients.  While we may think a one-size-fits-all approach is best when managing staff or patient treatment plans, thinking about how a person will respond to expectations gives us a better sense of how to communicate with them. Knowing each person’s tendency can help us work together more seamlessly and efficiently, and better manage conflict.

What are these Four Tendencies, and what can we learn about how to communicate better to each?


Upholders are self-directed and will faithfully follow advice from their healthcare provider.  They readily meet both internal and external obligations, and know what people expect from them (and what they expect from themselves).  They will keep their New Years resolutions, complete a marathon, and embrace rules and schedules.  These staff members are never late, get their work done, and thrive with a “check list” for obligations and expectations.  However, they may come across as “cold” or judgmental because they don’t understand why someone may be struggling. 

As patients, if an Upholder is told to take a drop once daily at bedtime, they will do it.  If told to replace their contact lenses every two weeks, they will put it in their calendar and never overwear their lenses.  They will show up for their annual exams to the day yearly, and never no show.  They love being pre-appointed, as they add it to their calendar and will never question or argue the need for annual exams.  They will strive for perfect compliance and rarely question the need for treatment.  They will follow recommendations from their healthcare provider, and rarely ask questions about different options or opinions.


Obligers respond well to external obligations, as they hate to let others down.  However, they struggle to meet inner expectations.  They are great team players and don’t want to let their team down.  They require supervision, respond well to deadlines, and often will do more for others than themselves.  They can be frustrating as staff members, as they may seem to lack initiative and are not seen as  “self starters”.  By understanding how they meet obligations, we can better manage them with more supervision and guidance.

As a patient, they respond well to communication such as “Mrs Smith, I look forward to seeing you in 3 months so we can monitor your glaucoma.”  They do not want to disappoint their doctor, and will continue their treatment and follow up as directed to fulfill that obligation.  If left open ended (“ call to schedule your next appt”, or “let us know how the new contact lenses are”), these patients will not be as accountable.


Questioners investigate all expectations – inner and outer. They want to know why they should do something, so they can meet their inner expectation and follow though.  They will resist outer expectations (“take this drop in both eyes at night”) unless given specific reasonings as to why they need to do this (“this drop works best to manage the fluctuation of your eye pressure overnight which is why it is taken at bedtime”).  They will need complete buy in of your recommendations and will only do as directed if presented with concrete, factual evidence.  These are patients who may even ask for research articles or literature that back up your prescriptions and will only follow your treatment if they respect your expertise.  They can often have “analysis paralysis” as they desire more and more information which can prevent them from making a decision.  In the optical, these patients should be shown a minimum number of frames and very few lens choices.  If presented with too many options and choices, they are most likely to leave without making a purchase.  Staff members should be aware of identifying these patients early so they minimize the decision making and be well equipped to answer any questions (with handouts, pamphlets and research!) the patient may have.   When pre-appointing these patients, they will ask “why do I need to be seen in a year?  What is the exact reasoning” – and staff members better be prepared with an answer.

My last Questioner patient required a hand drawn diagram about how pinhole acuity works to understand why my technician was performing this after cataract surgery. Had my staff member (or myself) said “we just need to do it”, we may have had pushback and confrontation. By explaining and drawing exactly what the test does and why it was needed from him, he immediately was put at ease and thanked me at the end of the exam for taking time with him. These patients may come in with a list of questions written down, and may seem to be difficult patients, but just have a strong need for all information before they can have trust in their practitioner and buy in for a treatment plan. They can often drain and overwhelm staff, but by knowing the reason for their behavior, we can have a better relationship. 

As staff members, they will not blindly follow processes and procedures and may drive staff and management crazy by questioning why something should be done a certain way. It can be easy to dismiss these staff members (“it has always been done this way, so do it!”) but if given good reasons to back up evidence and reasoning, they are more likely to follow.


Rebels like to do what they want, when they want, and how they want. If asked or told to do something, they are likely to resist. They also don’t like to tell themselves what to do, so they are unlikely to schedule things at certain times. They, unlike Upholders, respond poorly to routines and rules. Different than Obligers, they will fight against reminders, supervision and micromanaging. 

As patients, they will resist pre-appointments, as they don’t know where they will be in a year. These can be the toughest patients for compliance, and the ones we have the hardest time imparting the importance of following a routine. When prescribing a glaucoma medication, if told to take their medication at night, they will likely be our most non-compliant patients. They won’t ask questions; they will just flat out not comply. They will be the patients who don’t check their blood sugar or know their HgA1c, and change their contact lenses “when they hurt”, no matter how many conversations you have about safety and vision loss. How can we get the message through to these patients?  If we can appeal to their identity, we can often see great results. A conversation may go “Mrs Smith, I know you are now retired and have plans to travel the world. By not taking your glaucoma medication as prescribed, you run the risk of permanent vision loss.  Don’t you want to see the sights on your trips?” These patients want to live the life they want, so we need to communicate how they can do so. These patients may also need “tough love”- for example, “Mr Jones, if you continue to over-wear your contact lenses, you run the risk of a corneal ulcer, which can cause blindness. This is preventable, and is up to you.” Pushing a rebel to do something can lead to resistance, so leaving the decision in their hands can improve their compliance.

Rebel staff members can be challenging to manage, and tend to resist rules and rigidity.  Their behavior can often be seen as insubordination, lack of respect, and rude.  They can especially be difficult for an Upholder to manage.  When managing a Rebel, we have to realize their actions are not personal or a retaliation, and they are motivated differently.  By giving them freedom to tackle projects, and information about why things are needed to be done by specific times, they will be more likely to comply and have less pushback.  Rebels can be amazing team members- they think outside the box and are often a fresh breath of air- once it is understood how to work with them best.

While you can’t have each patient in your exam chair take the quiz, you may find it valuable as a staff training exercise.  It helps everyone identify best with a personality or category, and realize their strengths and areas of opportunities.  It also can alleviate stress and drama that can come with staff by figuring out better ways to talk to each other.  Ideally, we can also bring this information into the exam room, as an Upholder and a Rebel will respond differently to presentations about how best to treat their dry eye or manage their glaucoma.  By realizing this, we can have a more tailored approach to our patient care and have overall better compliance and office experience.

Yours in success-

Jennifer L. Stewart, OD

By Jennifer Stewart, OD

Optometrist, internationally recognized speaker, writer, consultant, and entrepreneur.


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