Myth of Medical Moderating
I grew up with older brothers that I idolized and in many ways continue to hold on tall pedestals. They were the authorities that I respected and did not question when they spoke. They knew the truth. Their wisdom was awe-inspiring.
Later, when they became physicians, their clout was turned up another notch, in my eyes as well as theirs. They knew the facts. They had studied. They made logical decisions based on data and reality. They were trained to do so. They had definite opinions on the right and wrong way to do things and were happy to tell you which, what, where, when and how. Interestingly, their views were clear, but their actions and choices did not always match up with the facts they’d present. It was the shoulds and oughts vs. everyday life behaviors.
The most personally satisfying moments, when I got to know who they really were, were during times of play or heart-to-heart conversations when they expressed their feelings or let out the fun parts of their personalities.
Picture this. It’s Christmas season on Fifth Avenue, around 6 p.m. on a crisp, cold, blustery night. You can hear the Salvation Army Santas ringing their little metal bells on the street corners. My brother Ben, his wife Clara, his two young daughters and I are marveling at the automated mannequins in the fantastic store windows. But we’re sooooo cold and getting hungry. Aha! We spy a soup kitchen with an assortment of hot, savory flavors and thick slabs of hearty bread. We hurry in to the warmth and the pungent aromas of garlic, onions, tomato, dill, chicken, butter and the yeasty scent of fresh-baked bread. Ben grabs a table right by the window, while we get in line. We choose our steamy bowls and rolls and bring them to the table. As we relish our delicious soups, people stop at the full-length window and peer in. Ben is closest to the glass. In a moment of silly inspiration, he mechanically brings his spoon to the bowl, scoops up some soup and instead of bringing it to his mouth, he robotically turns to the window with a maniacal grin on his face and offers it to passersby, who jump back in surprise and then laugh and point for others to check out the moving human dummy in the window.
I tell this story because if you only met Ben, the doctor, you would have a totally different impression of him than the one who was so playful in the soup-kitchen window. He’s very rational. Yet his behaviors and choices often differ from what he says, and they frequently reflect his more mischievous side or softer side. So, although he might understand that two medications are virtually identical in their profiles and would say he has no preference, in real life he demonstrates preference by choosing one over the other. If you brought this to his attention directly, he would feel pressured to rationalize his response in some logical way, which may or may not be the real reason he prescribes this way.
In research with physicians, we often have to understand the facts. Doctors are great at that. They’re trained to evaluate product profiles — what the products do, how they do it, the method of action, efficacy, expected outcomes, safety profiles and risk factors. However, we also need to get beyond the obvious to find out what this medication, device or procedure means to the doctor in terms of how it will help or hinder his/her practicing and feelings about self in doing so.
Just like with any other consumer, but even more so because of the physician’s training to stick to the data, we need to explore doctors’ beliefs and feelings indirectly in order to encourage their true attitudes to be expressed.
I recently experienced a dramatic example of this in an ongoing research project, where the first and second part were spearheaded by a client team member who was open to creative and psychological techniques, while the third part was managed by one of his cohorts who believed that only a logical approach could be used. Even though I tried to cajole him into opening the guide, he insisted on a regimented approach to a score of messages. You know the drill — main point, other points, type of patient it’s for, when would it be prescribed if this statement were true, benefit to patient, benefit to doctor.
The difference in response was remarkable. In prior research, using techniques that included guided imagery for brand, drawings, analogies and thought balloons showing the doctor/patient dialogue, the doctors were relaxed, animated and highly involved in the process, as well as able to tell us about how and why in ways that led to key insights for marketing. They were able to do so because the creative exercises allowed them to let down their guard and express themselves. They told us what it meant for them to be physicians in the first place and then were able to reveal how the medication was in keeping with their personal goals or not. It was different for different people.
You can guess what happened in the latter round. The doctors acted as though they were being tested. They had to search for the facts and give the right answer on 20 some statements presented to them. They were bored, annoyed, antsy and couldn’t wait for it to be over. They gave answers that were obvious, what they should say. It seemed like we could have written the report without conducting the research. It was just confirming the facts. I worked hard to bring some fresh news to the report, but I felt guilty that I had allowed myself to be corralled into this type of questioning when I knew it wouldn’t get them the answers they needed. My former client and I shrugged our shoulders and tried to make it better in the next phase.
In the many years our firm has been doing creative market research, we have heard complaints time and again (from our clients, peers and students) about the serious difficulties that qualitative research with medical professionals presents. In our opinion, many of these difficulties can be avoided with choice of approach and a little psychological savvy, and by recognizing and preparing for the pitfalls. What follows is a brief list of the more common problems and stereotypes that are frequently voiced, and a few simple strategies for overcoming them.
FACT OR FICTION?
“Doctors aren’t creative.”
Fiction! This perception often arises because many clients are fearful of taking an indirect approach to understanding medical branding and marketing. They have the idea that doctors will feel we are not taking them seriously and won’t be able to do the exercises.
In fact, creative exercises take the pressure off. Instead of having to come up with the right answer, this busy doctor can take time out, relax and have a little fun. Sometimes, a physician respondent will at first seem resistant to the idea of playing a game in the interview. It’s part of their training; they’re supposed to be serious. But for most, once they realize they have permission to let down their guard, they step up to the plate and play ball.
Just like with consumers and patients, it’s important to be prepared with a number of techniques. If one doesn’t work, try another one. Different approaches work with different people.
“It is disrespectful to ask doctors to take part in creativity exercises.”
Fiction! When approached properly, doctors welcome the opportunity to loosen their ties and be creative. The difficulty is that many moderators ignore the fact that doctors are constantly “on the line” or being evaluated in the office or hospital environment. Again, this puts them in the mindset to “produce the right answer,” which counters their creativity (and increases stress).
Few moderators are trained to eliminate or suspend this mindset. One simple way to encourage a creative mindset in a focus group might be with these instructions:
“Be creative, there are only right answers here. By the way, research shows that it really pays to put aside judgments of your ideas in a group process like this until they are all out on the table. That’s because we want everyone to get a chance to associate to your ideas, even if you may think the idea is not so hot.”
“You can’t get a doctor to take off his beeper/cell phone.”
You can, but you shouldn’t. A beeper is a doctor’s connection to her practice. When you remove it, you create high anxiety that is counterproductive to creative process. If a beeper goes off, turn to the doctor and ask her if she needs to make a phone call. If the answer is yes, then direct her to the phone and ask her to please hurry back. If it’s a group, you can say: “We’ll try to wait for you for the next exercise.” Don’t be too demanding, or too generous. If it’s an IDI, she can take it right there if she likes or walk out. “We can wait a minute. Go ahead.”
Keep in mind that your affect (tone of voice, facial expression, body language, etc.) should communicate the importance of both events (the doctor must return the phone call, and you must conduct the research). We have found that, with this approach, four out of five times, the doctors say that they can wait to return the call.
“Doctors have a diminished attention span in market research.”
Fiction! Doctors, of necessity, are forced to push their capacity for “secondary process” (logical, rational, goal-oriented) thinking past its limits on a daily basis. This leaves them feeling intellectually drained and much more willing to discuss their handicaps on the golf course than their perceptions of a new drug or advertising campaign. Fortunately, there are efficient psychosocial techniques that can be applied by a trained moderator to re-energize and pique a doctor’s interest.
Use creative exercises. These are refreshing interludes for the physician who has been operating under left-brain limitations all day. They provide a rest period from analytical thinking. Doctors often respond with enthusiasm and delight at their own creative processes. They find their reveries fascinating and are eager to discuss them.
They leave the interviewing experience smiling and energized instead of lethargic and grim.
“Doctors choose prescription medications because of their effect. Prescription medications have no imagery that affects doctors’ choices.”
Fiction! I can’t believe I’m still hearing this. Twenty five plus years of marketing research experience has led me to believe that imagery is associated with all products, and it is usually a major force driving prescriptive habits. Eliciting this imagery from doctors via projective techniques is simple once you have won the physician’s respect and attention.
“Women doctors are more creative than men.”
Both fact and fiction! There is a documented difference between sexes indicating that women are significantly more willing to discuss emotions than are men. We believe that this pre-existing difference is intensified by the “no emotional involvement” philosophy that is so often preached by the medical establishment. Since openness to one’s internal processes is often a cited pre-requisite for creativity, male health professionals may suffer on this attribute.
A trained moderator can easily minimize these differences and help individuals discuss emotional issues relevant to creative marketing research. The key is to create an atmosphere unlike the typical work atmosphere.
“The moderator must always call a doctor by his title and last name. It’s disrespectful to run a group on a first-name basis.”
Fact! Although it may be unfounded, experience has shown that doctors are somewhat insulted when addressed by their first names by a stranger. Many doctors, even those who know each other, address each other by title. While they might not admit it, they seem to feel as if their status and life achievements have gone unrecognized.
The safe route is to call any physician “Doctor,” as a matter of respect.
SOME OTHER POINTERS
Know who you’re dealing with before they come into the room or get on the phone.
In our screeners, we incorporate a quick personality assessment that we invented. It takes just a minute to administer. While it’s far from perfect, it mimics the Myers-Briggs personality test, which indicates preference for Extraversion vs. Introversion, Intuitive vs. Sensing, Thinking vs. Feeling and Judging vs. Perceiving. If you Google “MBTI,” you’ll find a wealth of information on these preferences, what they mean and the sixteen personality types, as well as various instruments that try to predict the personalities.
The reason this is important is that, if you know a bit about the doctor’s personality before- hand, you can predict the types of exercises you’ll need to do. For example, if you get an ENFP, this person will be very likely to jump into any creative exercise with hardly any preparation. The more out there, the better for this energetic, imaginative person.
At the other extreme, if you get an ISTJ, you might want to start with some easy-to-answer, logical questions and then move into analogies and metaphors to get at imagery. Also, if you’re having trouble with the most logical types, it helps to find the doctor’s metaphor. What are his activi- ties, interests or hobbies? Use that interest for under-standing the brand and its competitions, or the condition vs. other types of conditions. So, for example, if the physician likes baseball, ask him what position would each brand play and describe the way he sees that player. Or ask what sport personality would it be and to describe that person. Then tie this back to the brand.
Consider screening for creativity.
Include a measure of creativity in your screening instrument. One very simple measure of creativity, called “ideational fluency,” simply corresponds to the number of uses someone can report in a given amount of time for a given object. For example, you might ask physicians on the screener, “I’m going to time you for 45 seconds, and I’d like for you to tell me all the different uses you can think of for a paper clip.” Throw out anyone who gives you fewer than seven answers in that time period (ten, if you want to be really careful). You’ll find that the doctors remaining are more forthcoming and willing to use their “right brain” to help you accomplish the goals of the project.
Check out different instruments for measuring creative process. For example, over the years we’ve developed one that involves rating several self-descriptive paragraphs. This technique targets physicians who are willing to be more fluid in reacting to marketing stimuli.
Lastly, understand your personal reactions to doctors.
It is extremely important to explore your own personal, emotional reactions to physicians in detail because, more so than any “technique” you can learn in a textbook or a course, what makes you or breaks you in the interviewing room is your level of confidence and poise.
Keep in mind that your affect (tone of voice, facial expression, body language, etc.) should communicate the importance of both events (the doctor must return the phone call, and you must conduct the research). We have found that, with this approach, four out of five times, the doctors say that they can wait to return the call.
What are some of your earliest memories with physicians? What attitudes were you taught about how to behave, think and feel in their presence? How might these help or hinder your performance as a medical interviewer?
Most important is to remember that no matter how much someone may seem like a superstar for whatever reason, he or she is still a person with a heart and feelings and everyday behaviors like anyone else. And when gently and empathically encouraged, all of us are able to discuss are real feelings and beliefs.
About a year ago I was interviewing producers and directors. Fortunately, I’m not that well versed in the movie industry to be star- struck by people in these roles. On one day, however, I looked down at the summary sheet of respondents and saw that the next person on the list was Tim Robbins. Oh My God! I started hyperventilating, sweating, heart pounding, felt tongue-tied. Couldn’t believe how anxious I was. A few minutes later, in walked Tim Robbins, a short, redheaded 25-year-old with a strong lisp. Enough said.