You think you know the patient inside-out. But do you know the patient outside-in?
Published on 08 Jan 2020
By Emily South (and Kate Khair – contributing author)
Are we seeing the patient’s world as
clearly as we possibly can? Will a more complete picture help us to build
In business, making assumptions can be an important first
step to solving problems. But it can also bias us in how we frame the challenges,
the questions we ask, and the decisions we make. It’s the same for healthcare
market research and pharmaceutical interactions.
The way we think about individuals living with illness, and
how we design research and create solutions can be led by our own biases and
assumptions about people. For example, as stated by Lorraine M. Thirsk ( 2014
): “The focus on ‘self’ in ‘self-management’ can lead us to think about chronic
diseases as a largely independent activity and that people require individual solutions.”
In addition, the word ‘management’ implies there is a set of strategies that everyone can work with consistently and effectively.
When designing research methodologies, we tend to zoom in on
the main characters to learn about their experiences; the person living with
the illness, the physician…maybe even the carer or the nurse.
And when understanding prescribing behaviours, we focus in
on the physician-patient consultation. But what if this ‘individual focus’ is
not telling us the whole story? Do we miss out on a valuable part of the story?
Are the missing pieces key to the research objectives or to the brand we are
helping to build?
An individual focus may not be accurate. Chronic diseases
can be viewed in a more connected sense, “embedded in family, community and
societal conditions that shape and influence” (Kendall, 2010).
Furthermore (paraphrasing Fritz Heider), we are all unreliable witnesses of our own behaviour. This is complicated further with the emotional burden for people living with an illness, impacting what they are able to recall and sharing with us only what they believe we want to hear.
Challenging an ‘island view’
At THE PLANNING SHOP, we have been conducting research to
challenge what we call an ‘island view’ of the patient, by introducing
‘witnesses’ to our studies.
These are the people who are usually absent from research,
but who have an important perspective and can potentially influence management
and treatment. Taking severe haemophilia as an example, we recently completed a
piece of UK qualitative research to see if ‘witnesses’ add value to patient
research. We included witnesses to help us build a more complete picture and
uncover deeper insights that we believe can lead to more effective brand
From the outset we chose a more open approach to the study,
enabling us to include a wider range of roles – clinical and non-clinical – who
we would not normally speak with. The recruitment process involved:
Mapping all potential touchpoints of a person
living with haemophilia (people considered to be in their team)
Use of descriptive statements in the screening
materials to describe the potential influence and involvement of ‘witnesses’ as
well as the ‘main character’ roles
Inclusion of a diverse sample of individuals
viewing the haemophilia experience from different angles.
Our methodology included the use of indirect questioning,
self-discovery exercises and challenging different team members with different
viewpoints. We explored the most important connections and relationships with
remote and live in-home discussions to build both depth and breadth of
Before we move onto the research outcomes, let’s talk haemophilia. What is it?
Haemophilia is a rare, usually inherited, genetic disorder
that inhibits the blood’s ability to clot, with types A and B affecting
different clotting factors. 2017 UK annual data shows 9,639 people (mostly
males) living with haemophilia in total, with 2,295 severe cases. These numbers
exclude female carriers who may also have symptoms, and the wider sphere of
different family and friends for whom haemophilia impacts.
Haemophilia can be described as:
bleeding is the most identifiable sign, but it is often accompanied by chronic
joint pain and psycho-social issues. The combined limitations and lack of wider
community understanding can make haemophilia anti-social and isolating, lending
a wider meaning to ‘invisible’
even the most experienced person cannot always anticipate when or how
haemophilia will strike; a repetitive task at work, a night out with friends, a
simple knock at home or a trip on the pavement
Malicious: one day you might be busy with life, the next day you could be temporarily debilitated in a wheelchair, interrupting important plans and quality of life.
An underlying tension in the world of
With treatment advances – such as selfadministered factor
infusions – haemophilia care has moved from the hospital into the community. Comprehensive
Care Centres (CCCs) with inhouse multi-disciplinary clinical teams including
the haematologist, specialist nurse and physio (and psychologist in larger
centres), are now providing hubs of expertise designing treatment and
management plans, where people living with haemophilia can self-manage in the
community and live their lives.
However, our research uncovered an underlying tension in
haemophilia: living an independent life and self-growth, in a medicalised
system. A tension which results in an ongoing risk-benefit gamble for patients
and carers throughout their lives, with people asking themselves questions
“Is it worth the risk of a bleed or chronic
joint and pain issues?”
“Shall I follow the rules?”
“Who am I?”
Our research has shed light on how people living with haemophilia find their way around this tension.
Insight one: Identity and tackling the lion
To begin to explain this tension we need to tell a story
Nemea the lion was a vicious monster in Greek mythology and
Hercules had a huge task to conquer Nemea. After much persistence Hercules
killed the lion with the force of his hands. Once dead, he removed the skin of
the lion and used it like armour, making him invincible. In psychological
terms, to fight the lion means to face our deepest fears, but to accept our
weaknesses as part of our identity (wear the skin) is to be transformed.
Interestingly, the goal of being brave and wearing your
haemophilia with pride is what the HCPs we spoke to try to inspire people
living with haemophilia to do. Role models such as some patient influencers
wear their haemophilia in a similar way. Take Christian L Harris for example,
whose own severe haemophilia has inspired his fashion designs. Or Chris
Bombardier who is raising awareness by completing the seven summits challenge
with severe haemophilia.
But is this a realistic and desirable goal for all people
We see there are different and overlapping paths taken by
people living with the disorder:
– The regular guy:
through adjustments and adaptions haemophilia is kept in the background and
does not play a starring role. A sense of wellbeing and belonging is achieved
– Social withdrawal:
on the journey towards being a ‘regular guy,’ patients can be derailed by the
limitations placed on them by the disease leading to social withdrawal and
– Low self-worth:
their personal identity can be consumed by the negative associations of
haemophilia and they can experience a loss of self-worth.
Those who have been affected by the contaminated blood
crisis in the 1980s and blood borne viral illnesses may be particularly prone
to the ‘cul-desacs’.
The paths for someone living with haemophilia are not
consistent or straightforward, which lends value in understanding the
perspective of ‘witnesses’ who accompany them in their world.
Insight two: The haemophilia team
The people with haemophilia in our research acknowledged
that a team of individuals surrounds them. One person told us that he and his
team collectively form “one functional person”. When observing the carer parent
(typically Mums) and child team versus the adult team, we noticed that they are
different in size. The parent and child teams tend to be large and varied.
Adults have a smaller and intimate team. During clinical transition (from
paediatric to adult care), teens and young adults leave behind what was their
parents’ team and build their own trusted team from scratch.
Romantic partners or best friends are often the adult
patient’s most influential team members – more so than the medical team. This
team evolves over time through the course of different life events (e.g.
relocating, marriage, having children etc).
A partner or a best friend (unlike the medical team) can be confided in
over the long-term, offering regular emotional and practical support.
Our research showed that the clinical team, however,
perceived things differently. They acknowledged that the person living with
haemophilia has a team surrounding them, but they over-estimated the influence
of wider friends, immediate family and independent organisations or charities
rather than the trusted team. How does this happen? People living with
haemophilia stated how wider friends and immediate family “don’t get it,”
organisations don’t offer valuable support locally, or they are comfortable
with others not knowing too much because it creates too many questions and
distractions from their everyday lives. There may also be geographical,
cultural and religious reasons for people not being open about their health
Importantly, the clinical team over-estimated their own
influence, believing they offer more emotional support than people with
haemophilia think they do – sometimes under the guise of education.
There are three core reasons for these disconnects and
tensions from a clinical perspective:
The geographical distance of CCCs from people
living with haemophilia and their families and once or twice-yearly face to
face interactions with the clinical team
The physician focus on clinical aspects: ‘blood
and joints’ and the assumption that haemophilia is ‘manageable’ for everybody
Simultaneous trust and distrust: trust in
medical expertise, but lack of trust in the medical team’s understanding of
their lives and desires as a person.
The reality of living with haemophilia is complex. Patients
surround themselves with a trusted network of individuals. Speaking with these
team members is vital to understanding how people navigate their world with
The clinical perspective is not sufficient for understanding
this. The most critical team members are a subset of all the witnesses we spoke
to and represent a new target for research and brand building – the
Insight three: The unique perspective and influence of the
The ‘Outside-In’ team members of the person living with
haemophilia or parent carer:
Are not necessarily part of the
multi-disciplinary clinical team or part of family or friends
Have come from the outside and are now on the
inside, meaning they are able to give a fresh perspective on haemophilia (e.g.
a new romantic partner)
Know the person living with haemophilia or
parental carer inside-out.
In our research we identified many examples of ‘Outside-In’
team members – these individuals are in a unique position to not only share
their view of the person’s world and experience, but also to take an
influential role and effect change.
An example of an ‘Outside-In’ team member who took part in
our research is Sarah:
Sarah is the relatively new partner of John who lives with
severe haemophilia. As part of the research we conducted in their home, the
couple shared some interesting anecdotes:
Sarah activates and augments John’s engagement
with treatment. In discussions, John compared his adherence to treatment before
and after they met:
“I know sometimes they [the
bleeds] go untreated – I would say that’s quite rare now… 10% would get treated
previously, and 10% might be left untreated this time round.”
Sarah takes an ongoing role in monitoring and
communicating John’s treatment via a haematology app called the Haemtrack app.
John takes a more passive role. He said:
“I wouldn’t do that. I’d forget to be quite honest. So you’ve [Sarah]
got it on your phone. I haven’t got it on my phone.”
Sarah also helps to filter information to John
in a way she knows is digestible from sources online and by being an active
member of the Haemophilia Society (unlike John).
Haemophilia is not just about looking out for
the immediate patient. It’s about future generations too. During discussions
Sarah dropped the word ‘daughters’ into a conversation with John’s long-term
haematologist. This was planned to have a domino effect. Sarah had previously
recognised that John’s daughters from a past relationship were carriers of
haemophilia. They all knew this, but there were no proactive conversations
going on. John believed:
would have been on the [medical] record, but then it just gets lost.”
Sarah clarified that a conversation with the
doctor would never have been prompted by John or his doctor without her and
“Because of my career (as a
healthcare professional), I know what questions to ask… maybe nobody else
As a direct result of Sarah’s intervention John’s daughters
are now receiving adequate information on haemophilia and available treatments
and can start to plan their own families.
Sarah’s anecdotes show that the ‘Outside-In’ are highly
conscious of the person’s experience and are influential within their world. We
identified many other individuals like this, clinical and non-clinical.
For example, a support worker who had a unique birds eye
view of the multi-disciplinary team, and who also had a view of people who
would never usually take part in market research, and a young man having social
and housing issues who retreats to online gaming to actively avoid managing his
In summary the ‘Outside-In’:
Create positive adjustments and adaptations to
the person’s lifestyle
Are highly engaged and influential in treatment
Enable the people they care about to live in the
moment rather than reflect negatively on the past or worry about the future.
Ultimately the ‘Outside-In’ are creating resilience and
ongoing functional wellbeing – more complex than simply emotional or practical
support. As time moves on they expect to have an increased role in the lives of
the people they support with haemophilia.
We have picked out this specific group of individuals
because they are significant influencers and could help us to piece together a
more accurate picture of the patients’ experiences. Other team members were
valuable to speak with as well – especially in collaboration with the person
living with haemophilia. For example, where the individual with haemophilia
wasn’t able to express themselves, the team member was able to fill in the
gaps. Simply their presence in the conversation and acknowledgement of the
issues led to more natural and collaborative discussions.
Importantly, by speaking with the ‘Outside-In’ and other
team members, we were able to gain a more complete picture of the person’s
experiences with haemophilia and understand how the important tensions in
haemophilia mentioned earlier are currently being navigated, serving as a solid
platform for communications and solutions generation.
Our findings raise important considerations for the clinical
approach to haemophilia care in the UK National Health Service (NHS). The focus
on independence and self-management doesn’t necessarily reflect the reality of
what management in the community entails.
There is potentially a need to re-think how clinicians can
support and engage in the person’s world via their haemophilia team (as long as
privacy considerations allow). For example, adults who wish to bring their team
into the relationship with the clinical team should be encouraged (not judged
by the clinical team), because team members can add valuable insights impacting
personalised treatment and management decisions. It is also important to note that there is a
tipping point for new and innovative treatments – for example, will less need
for hospital delivered care lead to more isolation for haemophiliacs?
Outcomes and ideas
Brand engagement has come a long way since sales
representative product messaging to physicians. We have started to acknowledge
patients as engaged and influential people in treatment and management. It is
now time to zoom out to reveal the world of the person – a wider web of social
interactions and situations – a more complex system of decision influences and
triggers. We believe this broader picture is currently an untapped resource of
experiences and insights across therapy areas.
Solutions driven by
We have learned that the ‘Outside-In’ team have a
transformational effect and are important influencers in the world of the
person. We suggest brands tap into the problem-solving skills of the ‘Outside-In’
for solutions and ideas generation. As experts in the desires and quality of
life of people who happen to have an illness, and with experience in creating
lifestyle adjustments, the ‘Outside-In’ can help brands develop solutions that
connect better, are more sustainable and work beyond an individual level.
Brands need to be able to engage with multiple team
stakeholders and evolve tactics across life stages with channels and messages
tailored to the right people at the right time. When services are being
created, pharma brands need to be conscious of ‘connectability’ and input from
wider team members. For example, brands can create campaigns like Alzheimer’s
brands and charities that recognise the importance of the role of carers and
families. This idea can be built upon even further; taking inspiration from
consumer brands like Kraft and Premier Foods who are using insight gained from
family, friends and communities to create campaigns and tactics that are
tapping into the desire of connecting people together. One example is the Bisto
‘Together Project’, highlighting loneliness with their ‘Spare Chair Sunday’
project and bringing friends and family back together who have lost touch.
through the lens of life
We encourage brands to create a new language to be more
relatable. Patients are people living with an illness. Creating higher purpose
and communicating through the lens of life will create stronger positionings
and differentiation in crowded and clinically focused markets, ultimately
building trust. This is whether it’s helping the clinical team to quickly
understand the person’s context and desires in consultations to create tailored
solutions or creating resources that move beyond educating about narrow medical
moments to instead helping people to live their lives better.
It is a new era. We need to zoom out to understand the person’s world and experiences as clearly as we can. We need to understand all of the factors that influence them within their context. We need to use the ‘Outside-In’ to create valuable brands that speak to the people that use them.
About the authors
Emily South Innovation Director
Emily South is Innovation Director at THE PLANNING SHOP.
With a curiosity for people, stories and problem solving, Emily drives the
development of new research approaches and tools for effective brand building.
Emily has a BSc Hons in Anatomy and Human Biology, and
Biomedical Science from the University of Liverpool.
Kate Khair Chair of the nurses’ committee of the World Federation of Haemophilia
Dr Kate Khair is chair of the nurses’ committee of the World
Federation of Haemophilia and a leading specialist nurse in the UK, based at
Great Ormond Street Hospital, London.
Kendall, P. (2010). Investing in Prevention: Improving
Health and Creating Sustainability: the Provincial Health Officer’s Special
Report. Office of the Provincial Health Officer, British Columbia.
Lorraine M. Thirsk, A. M. (2014, Maya What is the ‘self’ in
chronic disease self-management? Retrieved from https://
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