Representative Gynaecology

I have a confession to make. Nothing salacious. Nothing morally or even ethically repugnant. Nothing, perhaps, even interesting, but it needs airing nevertheless. Like a clothesline full of underwear, it may seem embarrassing at first –shocking, even- but boring if it is watched too long.

I am not talking Wikileaks here; heads will not roll, nor empires crumble. And if CSIS or NSA put me on a watch list for it, well so be it. Some risks are necessary in medicine –it’s part of what we do. Part of the Hippocratic Oath.

Some things are beyond the pale when considered superficially; they require analysis. Digestion. And like looking through a glass darkly, they are not always what they seem at first glance. The poor man in his rags may be a god in disguise: the wandering stranger. Or, a god may be the Devil in disguise… The possibilities are endless.

The point is, there are lessons to be learned from every encounter. Every person. Every drug rep. So -full disclosure- I confess that I enjoy the give-and-take, the repartee, that inevitably accompanies their visits. And even if I do not fully appreciate the benefit of the product they are blessing, it is still a show worth watching. Worth interpreting. Worth arguing about.

Marie was a regular. A young woman in her thirties, she was always smartly dressed in bright colours so she stood out in a waiting room. Her hair was usually blond, and bunned, but occasionally she wore it streaked and hanging in loose waves that curled above her shoulder like whiffs of fine smoke. She was also tall -for emphasis I imagine. I always enjoyed Marie, although she often talked too fast, and in a sometimes delightfully garbled Quebecoise accent, so I frequently ended up listening to the sound rather than the substance of her message. I don’t think she noticed; she had only a short time to promulgate her information and make her pitch so her words spilled fast and furious. Fortunately the product was usually the same each time, so I could easily relax, bathe in the sounds she was producing, surface at the end seemingly refreshed by her presentation, and then ask a few generic questions and call it a day. It was win-win for us both.

But she caught me up one time.

“So, what do you think of our new product, doctor?” she asked, her eyes starry and her face a portrait of naive expectation: a child looking at her father for approval of her grades from school. But more likely, a trap to see if I had actually understood the concept. Marie is an incredibly intelligent woman –an otherwise unemployed PhD in biochemistry- who, I suspect, took the job with Big Pharma out of necessity rather than predilection. “Our company has just decided to detail it.”

I have to admit I really hadn’t heard much that I considered ‘new’ in what she’d said –she may not have talked about her product before, but there were already several other nail antifungal treatments on the market. And I was aware of most of them. Anyway, I confess that I had been distracted more than once by the gigantic earrings she was wearing: large hoops containing smaller hoops, all encrusted with shiny gemstones that were somehow attached to a gold filigree. With each enthusiastic shake of her head they bobbled and swayed, just missing the hair that danced off the platform of her shoulders. I became preoccupied with wondering if they ever found themselves entrapped in a curl or perhaps in someone innocently passing her on the street, unaware of the danger.

I was vaguely aware of some familiar words that had caught my attention, however, so I thought I would seek redemption by reiterating them in a neutral context to avoid embarrassment. “Well, efinaconazole sounds like good product for fungal infections of toenails, but it’s also rather expensive, don’t you think?”

She shrugged and her earrings shivered dangerously close to her hair. “Ahh, yes, but finally there is a medication that works, eh?” If she hadn’t been a drug rep, I would have sworn she winked at me. “The research, the premarket testing, not to mention the production costs and promotion –they all cost money.” She stared at me, curious about my reaction to such an un-Canadian and baldly capitalist statement of the for-profit side of the health industry.

“But… I mean, isn’t ninety dollars Canadian a bit steep for 6 ml. of topical solution? And requiring daily application for 48 weeks…?”

She smiled, but I could see it was forced. “Well, I never said how much the Canadian bottle holds… But I’m happy to hear that you already knew something about it.” Then, when I blushed, her face turned even more serious. “And imiquimod, our company’s topical immune cell enhancer, is expensive as well… But it can be a game changer, don’t you agree?” I could see her eyes daring me to challenge that  assertion.

It was my turn to shrug; she was right. Imiquimod was what she usually discussed on her visits to the office.

When she saw my resistance was transient and mild, her shoulders relaxed and she crossed her legs and sat back more comfortably in her chair. “Don’t forget that you only use one drop on regular toenails and two on the big toenail. And, although drop size is determined by force of extrusion, specific gravity, aperture diameter and so on, the average drop is only around 0.05 ml. –so, a 6 ml. bottle contains about 120 drops.” Her eyes widened to emphasize the importance of what she’d just disclosed. “So, if you are treating just the big toe once a day, for example, a bottle would last you 2 months…” She added that rather hastily I thought; I don’t think she wanted me to challenge her math.

I hadn’t known the size of a drop. My face turned humble, but I tried to preserve a little bit of defiance for pride’s sake. One last attempt at redeeming myself: “Yes, Marie, but suppose you have to treat all the toes each day? Say you’re a runner. Then a bottle would only last you…” I tried desperately to do the calculation on my fingers. “Uhmm, let’s see, four… plus two… then times two…” But the mathematical solution evaded me completely. I was under pressure, though.

“Ten days,” she added quietly. Thoughtfully. “But how many people have to treat all ten toes, eh?” Suddenly I could almost see a light go on, and she stared at me –or rather at my feet under the desk- secretly at first, and then with a little grin she couldn’t suppress even though I could see she was trying. “Unfortunately we don’t offer samples of the product to doctor’s offices, however…” Her eyes twinkled; she could see right through me.

In a way, I was relieved: I suspect I’d be easy to bribe…

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