Listening in

Editor's note: Liz George is a senior director of qualitative research focusing on life sciences and health care at Livonia, Mich.-based human behavior and analytics firm Escalent. 

Where some industries have the benefit of conducting ethnographic or observational research to gain insight into key conversations or decision-making moments, this is not always the case in health care. With my research in pharmaceuticals, it can be difficult to gain access to some of the most important conversations to learn from, because they happen behind exam room doors – and rightly so, as patient privacy is top industry priority. With the increasing challenge and value in learning from those closed-door conversations, creativity is needed to access the learnings from these interactions. Leveraging role-play is one approach to unlocking those insights. 

The gold standard for real-world insights is immersive, ethnographic research. However, there can be significant barriers that limit our abilities to conduct this style of research – particularly when our goals are to understand a specific decision or conversation that takes place in the journey of a disease state. 

Logistical hurdles. The coordination of finding patients and physicians at the right points in time and being able to secure consent from all parties can certainly be done but it often takes time that our clients simply do not have or it exceeds the budgets that would be reasonable. 

Regulations and privacy. The increasing protections of patient privacy are an essential component of today’s health care system but they create significant limitations for researchers seeking access to capture photography or video within physician practices. Added to that, while we may obtain a physician’s and patient’s consent to in-situ research, securing institutional permissions to access the practice is an entirely different challenge.

Ethical considerations. Having spent the last few years focused heavily in oncology business decisions, it’s clear to me that certain conversations deserve to remain sacrosanct between a patient and their physician. The moment when a patient receives a metastatic cancer diagnosis and is being explained their treatment plan is certainly a time where they deserve the privacy to react, emote, question and process – without additional eyes on them. 

In the full context

So, how can you achieve immersive learning without actual immersion? The answer is simple: simulation. Seasoned moderators often simulate conversations with physicians in the context of in-depth interviews. “Doctor, I’d like you to speak to me as if I were your patient and you were explaining this product to me.” It is an effective approach, except that the physician’s response is typically abbreviated, lasting about 45 seconds, when we know the full conversation takes as long as 30 minutes. Role-play, as a research tool, takes the same idea but immerses respondents in the full context of the conversation. The research team provides background, a simulated environment, a prepared actor, and we ask respondents to engage in a given conversation as they would in the real world. 

You may be surprised to learn how comfortable physicians are with role-play; in fact, it’s a core part of their medical training. Given that doctors speak with patients every day, placing them in a scenario to have a natural, reflexive conversation reveals more truth than asking them to recount such conversations artificially.

Role-play is an especially valuable methodology when core research objectives seek to understand a specific conversation, interaction or decision-making process. Where we might prefer ethnographic or in-situ observation, role-play provides a time- and cost-efficient alternative that yields similarly rich insights. Specific objectives that are a great fit for role-play include: understanding language or dialogue around a topic or product; exploring decision-making or recommendations in the moment; exploring how specific variables may shift decisions or conversation.

To help bring this idea to life, let’s set the scene: Our client, a global pharmaceutical company, was preparing for the launch of a first-in-class oncology treatment indicated for an advanced tumor. When approved, this product would change the existing treatment paradigm, as an addition to the current standard of care and, ultimately, change the nature of treatment conversations that physicians would have with patients. 

The challenge

Our team was eager to understand the dynamics and dialogue of today’s current treatment conversations around this tumor and its treatments. Because its product would be indicated as an additional adjuvant therapy, our client needed to ensure that its product’s positioning had synergy with the existing standard of care. But, the client was also eager to learn how that treatment conversation would change with the addition of its product. 

We could easily have relied on technology and applications to learn about the treatment conversations or even pursued other ways of simulating the conversation, such as virtual reality. However, we felt strongly that to really understand the human interaction between physician and patient, we needed a methodology that would allow us to fully explore both the rational and emotional dynamics of the conversation.

The preparation

Much like actual theater performance, all the hard work happens behind the scenes with role-play. Leveraging foundational patient research and deep knowledge of the disease state, we developed our scenarios and our patient personas. The actors cast to portray our patients were provided with more than a medical history – they were given in-depth lifestyle and family background, emotional character development and specific context about their disease (how they came to be diagnosed, their reaction in that moment, their underlying fears about the disease). We felt it was important that when these actors entered the simulation with a physician, they would be prepared to behave, speak and emote as realistically as possible. 

We know physicians will tailor their dialogue and explanations based on a patient’s needs and personality, so we prepared two different patient types that we had come to understand in foundational patient research: 

Joe: A blue-collar, semi-retired male who lives with his wife, he hates going to the doctor unless he really has to. He’s had a few health problems but relies on his doctor to tell him what to do. His wife does have to remind him to take care of himself and he only got himself checked out because she pushed him – and then he found it wasn’t just a cough; it was cancer.

Madelyn: A hard-working, ambitious corporate professional who puts all of her effort into her work, she’s never had any health issues before. But after a car accident, she had scans done in the ER and her cancer was discovered. She immediately went into action mode, reading everything she could and trying to figure out what her best options would be.

The creative approach

We prepared physicians at the recruitment phase to expect role-play as part of their participation in the research. The research engagement began with a brief discussion of their practice and the challenges of treating this tumor type. Then we set the scene for the first role-play by providing a patient chart, explaining that this was their first consult with Joe or Madelyn, where they would be reviewing the treatment plan. After observing the physician-patient conversation, we debriefed with the physicians to understand why they chose certain language or made certain decisions. Then, we showed a product profile and asked them to engage in a second role-play – this time in the hypothetical future when Product X was available. Again, our patient came in and the physicians engaged in the simulated “future state” conversation, followed by another debrief before the interview closed.

The outcomes

After conducting these role-play simulations in markets across the U.S., we discovered that by examining the dialogue of these conversations, we were also revealing key emotional learnings and valuable product insights. Our human approach took us beyond the conversation and into the unmet needs within this tumor setting. It helped us understand what was most important to physicians through what they shared with our patient actors. 

The unexpected and beneficial outcomes of the research included:

Direction for brand positioning territories. While physicians expressed receptivity to Product X, it was the observation of how expectations were framed to patients compared to the current treatment paradigm that revealed unmet needs and underlying physician tensions – creating paths to the brand’s positioning.

Language to inform brand messaging to health care providers (HCPs). Our detailed analysis of language and dialogue revealed valuable words, phrases and metaphors that directly informed message development.

Insight for disease state and patient messaging.  By listening and collecting the various terminology, analogies and explanations provided by the HCPs to the patient actors, the marketing team effectively built upon and employed these tried-and-true strategies in their campaign development.

Ensure success

In employing role-play as a health research methodology, here are a few notes from the director’s chair to help ensure success.

• Remember, it’s improv, not Broadway. It’s important to know that we did not give our patient actors a script to follow. Such a formulaic tactic would have dampened the human aspect of our approach. Part of why our physicians were able to engage in the simulation is because the actors behaved like real patients – depending on the character direction we gave our actors, they deferred or challenged, emoted or withheld, and interrupted the doctor with hard questions. Each engagement in the research was different, as the actors reacted and improvised based on the different language and approach the doctor took. The patient actors read and reacted to the doctor as a person, too, which is why we got closer to reality than other simulation exercises. 
• Learn, iterate and adapt. When we discovered in our initial conversation with a physician that he or she had a certain perspective or approach, we gave quick guidance to our actors to explore that feature somehow – prompting with a question or reacting emotionally to a specific phrase. One of the advantages of role-play is the ability to manipulate variables to understand how they influence dialogue, language or decision-making. 
• Preparation is everything. To prepare our actors, we had to deeply understand the patient experience, which required quality foundational research. It was only through real patient experiences and emotions that we were able to fully develop characters for these scenarios. Equally as important was preparation for our physician respondents – making them aware of the role-play in advance, providing any tools or materials they might need during the scenario and creating an environment that feels natural to them (an exam room or office).
• Consider the other influences in conversations. If decision-making is critical to the research objectives, it is essential to consider who else might need to be involved in the simulation. Are caregivers present? We may consider preparing caregiver actors to join our patients. Do different specialists work together to present the treatment plan? We may recruit both specialists and give them time to discuss the case before bringing the patient actor in. To learn effectively, it is essential to be thorough in simulating all of the appropriate variables. 

Must be relentless 

As researchers, we must be relentless in finding creative ways to access real-world human insights, even when the behaviors and decisions that we are after happen behind closed doors. Role-play is just one of our ways behind those doors.

While health care, pharma and finance face similar challenges and the privacy dynamic continues to evolve globally, clients across industries may find themselves working harder to observe decision-making that may once have been more accessible. When doors are closed, identifying ways to ethically and creatively access insights helps ensure we are not locked out.