Getting Doctors to Spill Their Guts Innovative Ways to Dig Deeper

1. Getting Doctors to Spill Their GutsInnovative Ways to Dig Deeper by Patricia Sabena & Nicole Sabena Feagin Sabena Qualitative Research Services Westport, Connecticut, USA

2. Why are doctors so difficult to interview deeply? • Arrogant, egotistical, sarcastic • Extremely literal, left-brained • Increasingly busy, overburdened • Increasingly resentful about $, HMOs • Limited by training, ‘book’ medicine • Fall back on comfort, habit, sales reps

3. What is the backgroundof this paper? • Straightforward qualitative research projects among physicians: • Often come away without much conviction that they have gotten to the bottom of what drives doctors • Especially in their treatment of the signs and symptoms of various disease states

4. What were the dishearteninghypotheses so far? • Physicians are not very emotionally involved in treating early warnings of cardiovascular risks because conditions tend to be asymptomatic and patients resist lifestyle changes and medications for: • Diabetes • High cholesterol • High blood pressure

5. What were the dishearteninghypotheses so far? • Despite recent medical findings and authoritative guidelines emphasizing the benefits of aggressive early treatment in preventing organ damage, morbidity and mortality, physicians: • Still proceeding very overcautiously • Not spending enough time with patients • Not emphasizing importance of medication

6. How do you switch the set-upto get doctors to spill their guts? • When each interview begins, tell doctors: • “This will be unlike what you may have experienced in previous research” • “Take a leap of faith,” “tap into your creative side” • “Don’t over think,” “just get into the moment” • Call doctors by their first names only, launch each interview immediately into projective techniques to avoid groupthink or physicianspeak

7. What projective techniques do we particularly recommend? • Scrap Art: turned into collages later • Heart Maps:rank order their priorities • Memory Storytelling: share their experiences • Sentence Completions: metaphors/analogies • Psychodrawings: typical user by class of drug • Tarot Cards: storytelling about archetypes

8. Magazine Scrap Art yields us 23 different collages! • Each doctor uses non-medical magazines to clip out and discuss pictures, words and phrases symbolizing their treatment of cardiovascular disease.(NOTE:These were later turned into themed collages by the interviewers, although each is represented here by a single image for proprietary reasons.) • Even the most basic themes manage to dimensionalize factors doctors consider in treatment: • Lifestyle risk factors (diet, obesity, alcohol, tobacco, stress) • Better choices (good diet, weight control, fitness, exercise) • Population sensitivities (African-Americans, patient as individuals, impotence concerns)

9. Magazine Scrap Art yields us 23 different collages! • The role of time (asymptomatic hidden killer, time bomb, long-term damage)

10. Magazine Scrap Art yields us 23 different collages! • Patient resistance (surprise, denial, vulnerability, non-compliance)

11. Magazine Scrap Art yields us 23 different collages! • Patient motivations (damage control, fighting the battle)

12. Magazine Scrap Art yields us 23 different collages! • Treatment strategies (simple, frustrating, confusing, innovative)

13. Magazine Scrap Art yields us 23 different collages! • Patient outcomes (victory, longevity, happiness)

14. Magazine Scrap Art yields us 23 different collages! • Physician engagement (teamwork, teaching role, adventure, leadership)

15. How does the Heart Map work? • Give a sheet of paper showing a red heart, and ask each physician to: • write down spatially and rank order by number • disease states, emotionally, closest to and farthest from his/her own heart

16. Heart Map yields revelations contradicting earlier hypotheses! • Our Internists, Family Practitioners and Cardiologists consistently rank diabetes, high cholesterol and high blood pressure as the “big three” they most like to treat: • Today’s newest Rx’s make a difference • These conditions are so ubiquitous • These conditions are so dangerous

17. Their “big three”: Diabetes High cholesterol High blood pressure Too minor, less engagement, less clear means to achieve results: acne, psoriasis, eczema, urinary infection, colds and sinusitis, gastritis, acid reflux, arthritis, migraines, obesity, smoking cessation Too difficult, unqualified, leaves them out of their depth without being able to help: Alzheimer’s, MS, AIDS, Parkinson’s, cancer, fibromyalgia, psychological disorders, substance abuse

18. What happens next with Memory Storytelling? • Completing the Scrap Art exercise and the Heart Map stir up or rekindle memories of good and bad treatment experiences • In sharp contrast to how they struggle or refuse to answer this same good/ bad treatment experience question by rescreener in the waiting room, doctors immediately and emotionally come up with remarkably detailed recollections

19. “A 50-year-old white female came to my office complaining of mild headache, a new patient. I suspected full metabolic syndrome because of her obesity and family history, and drew blood for tests for diabetes and hyperlipidemia. Her blood pressure was very high, 210/110. I began with combination therapy of ACEI and CCB and told her to come back in a few days. Her blood pressure went down to 140/90 and she was not complaining any more of a headache. I felt the combination therapy was the best suited, a little bit faster. The blood tests came back rather high in sugar and I felt really elated to have caught her Type 2 diabetes so early and to be able to counsel her about lifestyle changes and diet. I felt I had that supernatural power that I was able to help this lady (gestures heavenward to a higher power).” Cardiologist, California

20. “My worst memory is a 52-year-old African-American male with a long history of Type 2 diabetes, high cholesterol and hypertension. He had a stroke about eight years prior. He’s presently on about six drugs, including Clonidine, and fairly compliant. A few months ago he showed up at the emergency room with an intracerebral hemorrhage. He didn’t suffer a lot of sequelae from the stroke, but he still has some aphasia. Every time he comes into the office, I’m still worried about his cholesterol and his diabetes, and I’m scared to take his blood pressure.” Internist, North Carolina

21. Now doctors come up with dozens of different vivid Metaphors or Analogies • In this thoughtful frame-of-mind after their memory-based storytelling, give physicians Sentence Completion exercises asking them to come up with Analogies or Metaphors: • Treating diabetes (high cholesterol, high blood pressure, congestive heart failure) is like…

22. Now doctors come up with dozens of different vivid Metaphors or Analogies* • Encourage them to “borrow” Metaphors and Analogies by posting examples of “different worlds” on a flip chart: • Sports, politics • TV, movies • Fairy tales, games • Animals, cars • Food, beverages, etc. • *The metaphors and analogies from this research were so rich and so useful for the client that we are unable to disclose them.

23. What can Psychodrawingstell about doctors’ prescribing habits? • The most typical candidate for each particular class of drug (first line): • Body type, race, gender, clothing • First name, age, marital/ family status • Relevant health stats, co-morbidities • Personality/ lifestyle adjectives, objects • Sentence that captures patient’s attitude

24. Here’s a typical drawing by a doctorof an ARB user!

25. Here’s a typical drawing by a doctorof an ACE Inhibitor user!

26. Here’s a typical drawing by a doctorof a Beta Blocker user!

27. How can Tarot Cards serve asstimuli for understanding archetypes? • Using 42 cards of the Tarot, ask doctors to pick a few cards that symbolize their feelings, beliefs and values about being a doctor in the practice of medicine to treat specific disease states or risks • Their individual choices--and the stories they then tell about the cards they pick--reveal archetypes of their engagement, their roles, their doubts and frustrations, and their rewards • And yield many surprising outcomes that bust myths about today’s cynical stereotypes of physicians!

28. Much much less aboutpower and arrogance • Very very few choose “powerful” or despotic “rulers”

29. Much much more about the magic of healing • Many identify with “magic” by “waving a wand,” using a “bag of tricks” or giving a “potion” of drugs

30. Much more about saving and rescuing patients • Many talk about feeling like the “knight in shining armor” or the “warrior”

31. Much more doubts abouttheir own judgment and choices • Many concede “loneliness,” “challenge” and “frustration” in their decisions

32. Much more acknowledgementabout the role of luck • Some reveal their “insecurities” about the “hit or miss” of treatment

33. Considerable frustration with patientsin denial or non-compliance • They feel critical of “foolish” patients who ignore the dire consequences

34. Much joy and satisfactionin promoting healthy control • Ultimately they feel truly “happy” and genuinely “rewarded” when patients comply and improve their outcomes

35. Why is this relevant to you? • These techniques are not just for doctors but for executives, patients, teens, etc. • Anyone can be encouraged by these techniques to be more candid and authentic in their responses • The “be creative” set-up and--contrary to conventional wisdom--using projective techniques first, loosen up all respondents for deeper revelations about later topics

36. What are some important reminders? • Use these techniques respectfully and only when truly germane to the research objectives • Don’t use them unless you fully believe in them and can project your total confidence • Don’t let respondents labor over these. Urge “quickly, quickly” to allow time for other issues later on • Of course, you all know that Collage, Storytelling and Sentence Completions are certainly not new…

37. What are the new avenues? • But the Heart Map, Psychodrawings and Tarot Cards as stimuli do open up new avenues for understanding and communicating emotionally with many types of difficult respondents • In order to demonstrate how these work, try using the handouts in the context of your own job or product category

38. Using the Heart Map, yourself, writedown aspects of your own career • Closest to your heart, emotionally, using spatial nearness and rank order numbers • Farthest from your heart, emotionally, using spatial distance and rank order numbers • Share your favorite and least favorite aspects with another colleague • What do you have in common? How are you different?

39. Using Psychodrawings, yourself, compare users of two different products • On the left side, draw the most typical user of…. (say, Zyrtec) • Draw in facial features, draw/ label clothes • First name, age, family, work status, health • Draw/label holding most typical lifestyle object • List 5 personality and 5 lifestyle adjectives • Fill in full sentence of what person would say • Now, on the right side, do the same exercise for a competitive product user…(say, Singulair) • What were the main points of difference? What did you learn?

40. Using the Tarot Cards, yourself, pick a card that resonates with you • That best symbolizes your feelings, beliefs and values about being a doctor (or a patient) relative to a disease state you work on • Tell a story about that image that dramatizes why you picked it • With another colleague, brainstorm together how Tarot Cards might fit into insight mining your brands with patients or doctors

41. Getting Doctors to Spill Their GutsInnovative Ways to Dig Deeper by Patricia Sabena & Nicole Sabena Feagin Sabena Qualitative Research Services Westport, Connecticut, USA