The reflective mirror

Editor’s note: Dr. Murray Simon is a senior qualitative consultant with The Qualitative Institute, a division of Strategic Marketing Corporation, Bala Cynwyd, Pa.

I doubt that many of you reading the health care research articles in this issue of Quirk’s Marketing Research Review would argue with the statement that qualitative marketing research in health care is a tough job. It can be stimulating, challenging and very rewarding . . . but it is a tough job!

Qualitative research in other arenas, e.g., computer technology, the Internet, financial services, etc., can be complicated and demanding, but the intricate mosaic of details that comprise the universe of health care marketing research can make heavy demands on those who choose to explore its depths and nuances. Consider the following:

  • Membership in health insurance plans is in a constant state of flux. There is a prevailing attitude that suggests that medicine is looked upon as a commodity, with buyers always searching for a better deal.
  • If you are interviewing physicians, you are dealing with highly educated/trained/specialized people, some of whom are conflicted with regard to their professional careers - they have lost control of their profession and feel out of sync with their patients.
  • The technological changes are astounding and coming at a fast pace - designer drugs, minimally invasive surgery, ultra fast CAT scans, nuclear stress tests.
  • The dynamic interaction of the patient/manufacturer/provider trilogy is changing rapidly. One example, direct-to-consumer (DTC) advertising, represents a major variation in the way prescription drugs are marketed. While there may be some question as to whether it is here to stay, it has already had a significant impact and many professionals are having a hard time accepting the consequences.
  • Health care is suffering from a case of public relations trauma - the media is rife with articles relating to the high cost of medicine, complaints about the physician/patient interaction, hospital mergers and acquisitions, patient rights advocacy, etc. Many physicians complain about the frustration of having to deal with managed care’s dictates relative to the criteria for their treatment pathways: patients contend that their doctors focus on the disease and ignore the individual.

Which brings us to the subject of this article - managing sensitive personal issues in qualitative health care marketing research. For all its potential complexity, qualitative health care marketing research basically comes down to a dialogue between the moderator and the respondent(s), but experienced moderators know that the scope and intensity of the changes taking place in the health care arena are having a significant impact on emotional levels in the interview process. During a recent telephone interview with a radiation oncologist, I asked a question related to radiation dosages used with particular tumor types. There was a long silence followed by, "Are you sure you’re not working for some law firm that’s trying to gather standards of care information for a malpractice lawsuit?"

If a qualitative study has a strong emotional component, what are the best ways to make respondents comfortable enough to give the moderator the insights needed? Let’s look at some hypothetical, but not improbable, scenarios:

  • You have to moderate focus groups that will require your respondents to reveal some very personal details about their lives within a focus group setting. Erectile dysfunction is one potentially embarrassing subject that comes to mind. What can you, as the moderator, do to get these people to share deep-seated thoughts with a room full of strangers, thoughts they perhaps have not even shared with their spouses?
  • In conducting physician interviews or focus groups it is often productive to explore the why-not as well as the why, e.g., how negative clinical outcomes, surgical failures, etc., have influenced their therapeutic rationales. Medical school, however, does not devote a great deal of time teaching its students humility or candor and, with the threat of malpractice litigation always whispering in their ears, it is difficult to get doctors to talk about their failures.
  • In focus groups on skin augmentation/enhancement procedures with dermatologists and plastic surgeons (separate groups of course), it is pertinent to find out how each specialty views the other in terms of the competitive professional environment and how they might respond to it (would they expand their range of augmentation procedures, be quick to adopt new therapies, advertise, etc.?). The difficulty is not in getting these doctors to air their concerns, but to get them do it in a reasonably constructive and incisive manner (as opposed to a litany of professional character assassinations).
  • You are about to conduct interviews with culturally diverse respondents on women’s health issues. Are there ethnically related hot buttons you should be aware of before you begin? How will you use them to your advantage? How will you avoid those that should be avoided? Should you prepare separate discussion guides targeted to each audience?

Can you top this?

An exploration of these issues (and ultimately this article) is an outgrowth of a "can you top this?" luncheon discussion with one of my fellow moderators from The Qualitative Institute. Up until that time I thought I had faced the worst of the worst-case scenarios in terms of dealing with difficult/trying/personally sensitive research moments, but I found myself completely outdone by my colleague.

He had experiences with awkward research situations that made me look like a beginner, and he took great delight in telling me about them. This led to a series of interviews with other moderators at Strategic Marketing Corporation to gather input for this article. A simple request, "Tell me about awkward interview situations you have faced and how you dealt with them," inspired a flood of examples.

Much of this information will seem familiar to many of you and I make no claim for presenting cutting-edge techniques here, but my contributors and I were intrigued with the narratives this question prompted and the intensity of the responses it triggered - everyone wanted to know how their story stacked up against the others. The author hopes that by reading this article some of the more experienced players in health care marketing research will be challenged to re-examine the game’s fundamentals while some of the rookies will perhaps find new "moves" to add to their game.

Reflective mirror

The basic theme of this article - the reflective mirror as it relates to sensitive health care market research issues - first surfaced in a discussion with a female Asian moderator who was relating her experiences with interviewing women in China for a study on yeast infections. She recognized that she would be asking intimate lifestyle questions of women who are normally quite reluctant to discuss such matters with anyone, let alone a stranger. To make matters more difficult, she discovered that in China a moderator is perceived to be a highly educated and important person - someone an uneducated Chinese housewife would not be comfortable speaking with on any subject (but that cash incentive is hard to pass up).

The moderator’s problem was a matter of serious cultural and emotional issues that would inhibit responses. The solution she arrived at is perhaps obvious in retrospect but it worked well in this situation. She decided it was important to demystify the moderator in the respondents’ minds and then verbally fabricate a mental mirror that would allow her respondents to reflect their personal thoughts in the guise of observations about the people around them.

She started each interview by telling the respondents something about herself, with particular emphasis on having already completed similar interviews with several Chinese women. In the moderator’s own words, "I have conducted these interviews with many women and nothing you say can surprise me or disturb me." Through the use of this simple statement (and positive body language) she was able to demystify the moderator. She then erected the reflecting mirror by asking direct questions in an indirect manner, "Other married women have told me that they are sleeping in separate beds because of this condition. What do you think about that?"

By asking respondents what they thought about the actions of others, she accomplished two things:

1. She defined the scope and depth of the responses she expected, i.e., other married women . . . are sleeping in separate beds; this is not just about irritation or discomfort: I hope that you will discuss the impact of this problem on your lifestyle and personal relationships. She indicated how far the respondents were expected to go and acknowledged that others had already gone that far.

2. She gave her respondents a level of personal comfort and security by allowing them to frame their responses in the form of opinions and attitudes about others - "What do you think about that (them)?"

Very illuminating

While admittedly not exactly an earth-shattering revelation, this dual process of demystifying the moderator and erecting the mental mirror revealed itself in various guises throughout all of these moderator interviews and I think it is very illuminating to hear the different ways in which it was used.

For example, another researcher described individual depth interviews (IDIs) he had completed with patients suffering from end-stage prostate cancer. It became obvious early on that some of these patients were in denial and anticipated a dramatic turnaround in their prognosis. To ask these men to discuss problems relating to a terminal disease would have been too emotionally painful, especially in the context of a study exploring newer/better therapies (than the ones they were already on). It also ran the risk of interfering with the patient/doctor interaction. The reflective mirror, in this case, took the form of questions such as, "From others I have interviewed I’ve learned that bone pain is sometimes a consequence of this type of disease and I would like to know what your experiences and thoughts are on bone pain."

I have moderated a number of physician focus groups and IDIs in which the challenge was to motivate them to discuss their problems and/or therapeutic failures. In these litigious times, that is becoming increasingly more difficult to do. In terms of demystifying the moderator, I have a built-in advantage that gives me a bit of an edge - as a former dentist I can let respondents know that I spent many years treating patients and have had my share of cases that just did not work out.

If you have an edge, exploit it whenever you can! For those who do not, the best approach is to acknowledge at the appropriate point in the interview or group that you are going to ask questions that might be somewhat controversial (e.g., How do adverse clinical outcomes in this drug category influence your treatment decisions?), emphasize your impartiality as a professional moderator who has discussed sensitive issues with physicians many times before and re-confirm that strict confidentiality is being maintained - then ask the questions, look serious and wait.

In interviews or focus groups with physicians, the second phase of our paradigm, erecting the reflecting mirror, is often the easier of the two tasks - frame all questions in the third-person, "As a professional who has been in practice several years, I’m sure you’ve observed situations in which some of your colleagues’ clinical outcomes did not meet diagnostic expectations. Tell me about some of these situations."

Lifestyle club

In another example, a female colleague described a series of focus groups she had moderated on the subject of erectile dysfunction (ED) with female partners of men who have ED. In response to a question on efforts to find solutions and resources a respondent started to describe a "lifestyle club" that she and her husband belonged to. It quickly became apparent to the moderator that this "club" was founded on the theory that sex with various women is beneficial for the problem and that this woman was basically describing an ongoing house-to-house sex party.

The moderator became concerned about jarring what, up until that time, had been a smoothly running group. She realized it would be best to quickly end this line of conversation and not give the rest of the group an opportunity to embarrass the woman with their comments. Her first instinct was to personally display no overt reactions. She knew that if her body language registered disapproval, the respondents would mirror her response. She demystified the woman’s comments by interrupting her with, "Okay, I understand. That’s interesting. Did it help? Thank you." and then quickly raised a new question and moved on in a totally different direction. Later comments from this same respondent caused the moderator to conclude that she was sincere (if perhaps somewhat misguided) and would have been hurt by any untoward remarks on the part of the group.

The winner

And finally there is the experience of my luncheon colleague - clearly the winner in our duel over worst-case scenarios. He found himself in the situation of having to moderate focus groups with women who suffer from urinary incontinence. Humor comes quite naturally to this individual and he chose to use self-deprecating humor to demystify the moderator. His first comment to each group was, "The subject to be discussed is urinary incontinence and you’re probably wondering what career-ending move I made that resulted in my being here today."

At another point in his introductory remarks he acknowledged the sensitivity of the situation with, "When I think of you volunteering to come here today to discuss this subject, I realize that it took a lot of courage." He encouraged participation with, "Your input here today will be used to help others with this same problem."

The reflective mirror in this case took the form of pointing out that this focus group represented a unique opportunity to hear from other people at the table who know what each respondent was going through. These focus groups proved to be a very satisfying experience for this moderator: What started out as a particularly tough assignment (especially for a man) resulted in groups that were cooperative, candid and that generated a solid body of information for his client.

Extend education

There were additional comments during my discussions with my colleagues that are worth noting:

  • A lot of the health care market research being conducted today relates to quality of life issues, e.g., hormone replacement therapy, diet and exercise versus drug therapy for the control of hypertension, sexual dysfunction, etc. A moderator has to extend his/her pre-project self-education beyond an understanding of the pharmacology or therapeutic dynamics of the products being investigated.

You have to explore the deeper, underlying currents that often influence decision making processes, e.g., how hard is a physician willing to "push" patients to use a drug that works well but requires carefully timed, multiple daily doses (efficacy versus compliance issues)? What are the contributing motivational factors to anticipate in discussing drug therapy with diabetic patients? Many women consider osteoporosis to be "an old woman’s disease" - how do you get younger women to give it serious thought within the context of a discussion of hormone replacement therapy?

  • I recently came across a clever term for a well-established, basic tenet of qualitative marketing research - "sophisticated naiveté." This may be defined as "thorough preparation and self-education prior to the project, coupled with feigned ignorance during the study." It provides a subtle but effective means for probing or challenging - the respondents’ efforts to simplify and explain will often expose underlying factors that impact their thoughts and attitudes. Sophisticated naiveté can take many guises: the one I use most often is, "Remember doctor, you’re talking to an ex-dentist. Could you ramp that down for me just a bit?" Whenever it suits the purpose of the study, a moderator should invoke sophisticated naiveté in asking for clarification (e.g., "I’m sorry - I’m not a physician - it’s not clear to me what you meant by that. Please run it by me again . . . how do the rest of you feel about this?").
  • The first few minutes of any interview or focus group - the warm-up - is a critical time for establishing respondent confidence in the integrity of the moderator and the research process. In studies involving sensitive issues, it is also the appropriate time to begin the process of demystifying the moderator and acknowledging the sensitive aspects of the discussion.
  • In dealing with issues that have a potentially emotional impact, a time-honored marketing research principle is to begin with questions that are somewhat abstract and work towards the specific. In focus groups with chiropractors, I quickly discovered that the subject of pain management generated a more emotional/philosophical level of responses compared to the physicians I had interviewed - most likely related to significant differences in their training and philosophies of treatment. Instead of starting out with "Describe your therapeutic ladder for pain management," it proved more productive to begin the chiropractor groups with an abstract, "What role does pain generally play with regard to patient management problems and therapies?" Once they were sure I "knew where they were coming from" (and my body language connoted appropriate deference towards their treatment methods), the needed information poured forth.

Moving from the abstract to the specific works well with chiropractors but it can also be a very effective strategy for interviews with a wide range of professionals. It eases respondents into the subject, makes them more comfortable with the process and often yields more insights.

I sincerely hope this process of demystifying the moderator and erecting the reflective mirror will prove of value to those of you who actively deal with qualitative health care marketing research issues.

In recognition of those who told me of their experiences and graciously allowed me to narrate them (and to my ex-officio editors), I would like to extend my gratitude to Terri Maciolek, Bernie Schwartz, Bob Kernish, Grace Chin, Donna Caldwell, Juliet Goodfriend and Laurie Harris for their important contributions to this article.