The great debate

Editor’s note: Cheryl Ladd is president of Ladd Research Group, Cincinnati.

Consider the following case study involving the treatment of subarachnoid (brain) hemorrhages (SAH). Currently, there are two methods of treating SAH: surgical treatment by a neurosurgeon, which involves placing clips around the base of the aneurysm via open surgery, to prevent bleeding; and endovascular treatment by an interventional neuroradiologist, a newer technique which involves placing a coil into the aneurysm by means of a catheter (i.e., not requiring open surgery). At the time of this case, open surgical clipping was being done in a far greater percent of cases than endovascular coiling.

A new, prospective, randomized study comparing these two treatment modalities and showing potentially favorable results for endovascular coiling versus open surgical clipping was about to be published in a peer-reviewed journal. Our client was interested in understanding what influence this study might have on procedure volumes and referrals for endovascular coiling. Since neurosurgeons are typically the gatekeepers for these patients and are often the primary decision maker on which treatment a patient receives, focus groups were to be conducted with this specialty. However, because these neurosurgeons are for the most part biased toward surgery, there was concern that the discussions would be one-sided and focused on finding the negatives of the study.

To overcome this, we decided to include a debate format in the focus groups. In this format, the neurosurgeons were divided into two teams. One team was assigned to argue for endovascular coiling and against surgery, the other for surgery and against endovascular coiling. They were instructed to use the new data, abstracts of other articles that had been published comparing the two modalities which we also provided, their own experience and/or other studies they were aware of to build a case for their assigned technique, and to prepare rebuttals to what they expected to hear from the opposing team. They were separated on either side of the focus group room and given 25 minutes to prepare their arguments. They were given flip charts to develop their arguments and list the supporting points.

When we reconvened, we used a coin toss to determine which group would begin. Each team was given time to present their case, using supporting data. They were then able to rebut the other team’s arguments for as long as it took to exhaust all the pros and cons of all the articles and data.

While we did not adhere strictly to the time limits used in debates, we did request that the physicians remain in character throughout the debate - in other words, even if they agreed with a point the other side was making, they were to continue to defend their assigned technique.

Valuable exercise

This proved to be a valuable exercise for this particular case. The physicians enjoyed the process as it was out of the norm for typical market research projects and kept them more energized and involved. It gave them a low-risk opportunity to express viewpoints that perhaps they would not have admitted in a traditional discussion, i.e., they could support a technique that would essentially result in them losing procedure volumes. And it provided a format for them to truly look for positives for both sides of the argument.

The clients gained an understanding of how various aspects of the data would be used both for and against endovascular coiling. They learned how neurosurgeons would attack the data from the new article to prove that endovascular coiling was NOT better than surgery. By the same token, they also saw how they could present the data in the most favorable light, which aspects of the data might be most persuasive, or what additional data would be needed to change those views.

In essence the physicians provided the client with the “here’s what I’m going to say to you when you show me this article and try to convince me to refer more patients for endovascular coiling” information, so the client could be prepared for these potential objections. Of course the client could have expected to get this through more traditional focus group discussions. But the debate also showed the client how to skirt these roadblocks. The physicians themselves formulated the “but here are the nuances that are potentially persuasive, and if you combine this data with this data, or point out this flaw, it becomes more convincing” arguments. This information may not have come out in a more traditional group setting.

Used with patients

Debate or variations thereof can be used in other market research situations as well. A similar type of debate exercise might be used with patients to understand the pros and cons of two different therapeutic or diagnostic options. For example, consider a company developing a new method of permanent birth control for women - a less invasive means of performing a tubal ligation which involves inserting something into the tubes to permanently block the tubes as opposed to tying or cutting the tubes in a surgical procedure. In focus groups, women could be provided with a detailed description of the product, procedure, recovery, statistics, insurance information, etc. Similar to the physicians, they could be placed into teams and asked to debate for or against the new procedure. This allows them to look for all the pros and cons without the concern of judgment since they have been assigned to their particular viewpoint. Of course other techniques can be used before and after this exercise to ensure that the study sponsor understands each respondent’s thoughts on the procedure prior to the exercise and whether or not their thoughts changed as a result of the exercise.

We have also used debate in doing positioning research for new pharmaceutical products. In these situations, physicians are provided with the data on the new product, along with the data and current marketing pieces for the competitive products. A short “positioning 101” is given to provide physicians with an understanding of what the marketing team is looking to accomplish. Physicians are paired up, or put into a couple of teams, depending on the size of the group. We like to have three to four teams for this exercise. Each pair or team is asked to develop a positioning statement for the new product that they believe highlights its advantages versus the competition, taking into consideration the desire to also achieve the largest share of sales. In addition to the positioning statement, they are asked to provide supporting “reasons to believe.” Each pair or team is then asked to present their positioning statement and reasons to believe. The group then debates the pros and cons of each of the positioning statements. This shows the client the upsides and the downsides of each potential positioning, and helps them better understand the way the product is being perceived versus the competition from the physician’s perspective.

A variation on this would be to provide data on the new product as well as the competitive products and assign each pair or team to develop a positioning statement for one of the products - present them and then debate them among themselves. This provides more insight into the physicians’ views on the competitive products.

Effective and stimulating

Certainly, other tools could be used in all of these situations to glean similar insights. One might argue that in the case study for the endovascular coiling, the client could have gotten similar information by conducting focus groups with interventional neuroradiologists as well (those who do the endovascular coiling) - to gain the opposite perspective. However, since the neurosurgeon is the gatekeeper, it was beneficial to understand how they would convince themselves because they are the ones deciding what treatment a patient receives. We conclude that in this case, the debate proved to be an effective and stimulating technique for accomplishing the objectives for this project, and that it can be successfully used in other situations to gain additional insights.