tales of how pharmaceutical companies cater to the material
needs of doctors: case report
Ioannis A Giannakakis,
general practitioner a, John P
A Ioannidis, chairman b.
of Hygiene and Epidemiology, University of Ioannina School of
Medicine, Ioannina 45110, Greece, b Clinical
Trials and Evidence-Based Medicine Unit, University of
Ioannina School of Medicine
to: J P A Ioannidis firstname.lastname@example.org
To describe how pharmaceutical companies cater to
the material needs of doctors.
Design: Case report of memoirs.
Setting: Facilities that have nothing to do with
medicine, somewhere in the Arabian peninsula.
Patient population: Random sample of doctors.
Interventions: Promotion by the pharmaceutical industry.
Main outcome measures: Short term outcomes were travel,
pleasure, amusement, and gifts, and long term
outcomes were the market share of specific companies.
Results: Short term outcomes were heterogeneous,
underlying the diversity of the means employed by
the pharmaceutical industry to subvert, divert, and
influence medical practice. Overall, 200 doctors
were dressed in white gowns, a doctor in preventive medicine
quoted Hippocrates in favour of smoking, a senior doctor
became a poet, a doctor trying to understand the
Methods section of a poster paper wondered whether
he should have been sunbathing at the beach
instead, and two women doctors were kidnapped by Bedouin warriors.
Long term outcomes on the sales of the company drugs are
pending but are likely to be most favourable.
Conclusions: Eat, drink, be merry, and boost prescriptions.
A warm night at
the end of May, sky full of stars. I am floating supine on the
Dead Sea. There is no need to move my arms or legs,
no need to try to swim; just relax. The lifting power of
the water is all that is needed; it's like floating in outer
space without gravity. It feels good; I am content.
experience be related to the way I practise medicine? Can it
really influence and modify the way I diagnose and treat
patients in my daily practice? Just follow the story.
I have not been
alone for the past two days. I am staying at a luxury hotel
with 200 other doctors from Greece. When we arrived we
found flowers, avocados, pineapples, and white coats waiting
for us in our rooms. We have been dressed in white sincenot
the medical coat, as you might think, but the
traditional Arabian dress of a long gown with wide
sleeves and an Arabian kerchief for the head. The
women wear white silk dresses with fine embroidery.
I get out of the
sea to take a shower. Salt is burning my senses. Time for
food. There are tents at the beach. Under the tents, low
tables are loaded with delicious Arabian dishes. Wine flows.
We recline on pillows, as Bedouins do, and eat. Two
hundred people eating, drinking, joking with each
other, and having fun. When the dinner is over,
many of my colleagues try smoking the traditional Ottoman
pipe, with its pure tobacco burning at the bottom of a large
glass bottle. "Down with the antismoking efforts! Life is
short, said Hippocrates; enjoy it" exclaims one of
our colleagues in preventive medicine, a passionate
smoker, shaking the mouthpiece in his hand.
surrounds us, first softly, then louder, more forceful,
exuberant. This is a real beach party. Almost everyone is
dancing, singing, drinking, and being merry. But here comes
the greatest moment. A beautiful little khanum is
presented, a girl of 18, her perfect half
naked body sparkling with jewels and
semitransparent silk, her long dark hair shaking on her
shoulders as she performs the belly dance to the
sound of drums and flutes. A real temptation. Who
can resist? Not the poor middle aged doctor who has
lived all his life in a little Greek city in the north, with
more rain than London and more fog than San Francisco. He
works endless hoursharsh
and with no enjoyment. He is one of the most
successful practitioners, people say, judging from the bulk
of his clientele, one of the best connected. He hasn't had
a proper holiday for years. He is known to be terse,
dedicated, and professional. And now, it seems that
his destiny is in front of him, the little khanum.
She is getting closer, rocking her body. At first
he cannot move, his eyes are wide open. She is still
there, surrounding him with her arms, without touching him.
He catches his breath, then slowly tries to follow her
dance. His mind is lost. He is wrapped in his own
ecstasy. He is drunk, smiling, and happy. At last
he jumps from his pillows, exclaiming in an
explosion of emotions in a language that the girl cannot comprehend,
but all of us do, "Keep dancing my soul, keep dancing
my queen, and I will prescribe any drug the company
wants, keep dancing my mermaid, my dream, and I
will fill all my prescription pads with XXXX, keep
shaking your alabaster little belly, keep dancing
my little pigeon . . . ." We are
witnessing the birth of a poet, even if this poet
legend has it for many of the great alcoholic poets
of the Orient (and the Occident).
By the way, XXXX
is the new antihypertensive agent recently marketed by our
host. Let me clarify things. Obviously, the company has
paid for all our expenses. Yes, we have been escorted by
company representatives, the same ones who visit me
and the others in our practices. Actually, they are
the ones seven and 10 pillows away, one of
them clapping his hands at the poetic outburst. We have
not, however, heard a single word about XXXX or any other
drug on this tripnot
on the plane, not in the hotel, not on our excursions
in the desert, nowhere. No word was uttered about drugs, no
education was offered, no lecture for medicine was made, the
aim was just fun. When one of the representatives
approached me a month ago, the message was clear:
"we want to offer you a five day exotic trip
for free. There will be no medicine stuff involved, don't
worry, just pure fun."
That promise was
kept. It is not the same as when companies pay your expenses
for attending a scientific meeting.
We are all
familiar with the influential 27th or something international
conference of YYYY, where YYYY stands for some very important
medical subspecialty and where this is the most attended meeting
in the field. The companies ship hundreds of physicians and
their families (dogs and all sometimes) to the meeting to
promote their medical education. You struggle to find
the poster session, but it is hidden in a corner
behind the 10 metre high pagoda erected to
honour the new drugs "revolutionising the therapeutics
of your specialty," as the motto says on your
badge. When you unearth the relevant poster it is
pretty difficult to concentrate on the Methods
section as the loud dialogue unfolds at your back. "Where
did you go last night?" "We had great fun at the
casino; the company paid it all. Then they took us
out for dancing." "We went to the company
reception at the old castle; pretty boring, but the
dinner was good." "I spent the day in the sauna
yesterday. We also did some good shopping. I found
a nice leather bag, but didn't have enough money
with me, so I am going back to get it today. Do you
want to join me?" "Unfortunately, I am waiting for
a friend to take me to the beach. Check with the
representative, I bet they can buy the bag for
you." Then you look around, and you realise
that the only other person there is someone who is waiting
anxiously to be taken to the beach. No, I am not talking about
the kind of meetings that promote the frontiers of medical
science and education and where even the watermelons at
the company reception have the name of "the
most powerful H1 blocker on earth" stamped
on them or where you even find a pamphlet with the same wording
under your pillow when you go to sleepto
remind you that "compared with others, it
doesn't cause drowsiness and sleepiness." No,
this was a magnanimous, disinterested offer to the hard
working medical community. "A simple way to
say thank you" as one representative had told
me. The company and its interests were silenced to our pleasure.
Well, to be
honest, we did see the name of the company in a couple of tiny
spots. For example, it had hired a train and, as we
boarded, we realised that the whole train had been named after
the company. We were told that it was the same train
used at the time of Lawrence of Arabia, going all
the way to Mecca.
The scenery was
serene and inspiring, the desert was magnificent. Then we saw
dust over the hills. It was not a storm. Ten Bedouin
warriors on black Arabian horses appeared, rifles in hand.
Some of us stepped on the open side of the wagons to see
them better and take pictures. The train was moving
relatively slowly, and the horses were soon
galloping on our side. "Just like the movie!"
a doctor exclaimed, snapping away. She had hardly finished
her exclamation, when the leading Bedouin approached,
grasped her by the waist and, despite her screams,
seated her in front of him. A friend of hers was
grabbed by another warrior, with a long dark beard.
Never mind what Lawrence of Arabia would have done,
we were watching the kidnap evolve in awe, trying to think
what Popeye would have done if this had happened to
Olive. Then some of us started taking pictures of
the Bedouins, who were distancing themselves. The
representatives explained that the women would be
fine and that we would see them back at the hotel, unless a
real love story were to unfold in the interim.
Contributors: The ideas for this tale belong to the anonymous
geniuses working in the promoting and advertising sections of
a powerful pharmaceutical companywithout
their ridiculous ingenuity, this ridiculous piece would never
have been written. We won't mention the name of the companyit
is everywhere anyhow, although admittedly the London subway
has not been named after it yet. Only IAG had the benefit of
the live Arabian experience; he wrote a first draft and
contributed the material. The idea for writing this up as a
scientific case report-memoirs belongs to JPAI who, besides
setting the style, summed up the abstract, expanded the draft,
and invoked a title.