Papers

Arabian nights1001 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. 

^a Department 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

Correspondence to: J P A Ioannidis jioannid{at}cc.uoi.gr

	Abstract

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Objective: 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.

	Introduction

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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.

Could this 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.

	Case report

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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.

Exotic music 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 is drunklike legend has it for many of the great alcoholic poets of the Orient (and the Occident).

The scenery was . . . magnificent

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.

	Discussion

Top Abstract Introduction Case report Discussion

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.

	Acknowledgments

   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.

	Footnotes

Competing interests: None declared.