There was no study. An N of one. N, as in nothing, nothing to discuss.
Soren hadn’t wanted the project; it was just something he’d inherited when he took over the job. Munin had already been signed up, he was recruiting patients. The preliminary reports looked highly promising. But that was in September.
When they heard the news about Munin in December, well, it was godawful timing, of course. Something of a favourite topic at Janus; they’d all heard the story. Nothing first-hand: Munin was away from the office, off the radar, the sales rep hadn’t been able to see him for months. Soren’s calls weren’t returned. There was no response to his emails.
The VP of marketing pulled Soren aside after the sales-forecasting meeting. “Listen, Sor, this is a business like any other. Your customers —” what they called the physicians they solicited “— you can’t really trust them. They’ve got their own agenda. You take a situation like this ...” But what was the situation? Soren couldn’t find out. Was Munin on some sort of sabbatical? No one seemed to know when he was coming back. A secretary assured Soren that Dr. Munin would certainly return his calls once he was back in the office. Any idea when that will be ...?
Well, Soren couldn’t wait. He had to get this thing nailed down. More phone calls. So many emails that the university server flagged him as spam; another two weeks to sort out that mess. Then the holiday season and no hope in hell of contacting anyone. On New Year’s Eve he sent a registered letter: We would like you to present a case at the annual meeting in five months’ time. Silence. In January he went to Montreal and called on the hospital. Yes, Dr. Munin’s here. Not here exactly, at work. It’s his clinic day. Tomorrow would be better.
He returned the next day. No Munin.
For three days Soren waited, pacing from hospital to hotel room and back again. He stayed in his room, a business hotel on Sherbrooke Street, chrome-and-glass austerity so Scandinavian that it seemed to be mocking him. What are you doing here? hissed the Svanstaler chair. Fool — you should never have left home! bawled the Biedermeier bed.
He took to walking great distances, from the Old Port to the top of the mountain, the river view grim as an Edda in the damp winter air. Soren kept his cellphone on, but when it rang it was always head office pressuring him for an update. Are you on top of things? What have you found out? Where’s your report?What’s going on with Munin?
He was at the Trudeau airport business lounge scrolling through emails when he received a call from someone in Munin’s office. “I believe you wanted to speak with him?”
“I’ve been trying for three days. Is he there?”
“This is his office returning your call.”
“This is most urgent.”
“Are you a patient? Are you thinking about harming yourself?”
Harm was there on the horizon — to himself, Munin, career, prospects — but he told her no, it was a business matter. Not much time. He wanted Dr. Munin to present a case at a meeting in May.
“Then there’s still time,” the assistant said. Her calm was maddening.
“You don’t understand.” They were talking about months of prep work. Before the submissions and approvals there had to be talk among investigators, a pre-market push. Enough buzz to stir up some out-of-indication sales — nothing grand, expectations still European in their modesty, but they had to show something on the books. He’d worked the numbers. The major depression indication was worth a fortune, but there was no more room for growth. After a couple of billion dollars a year, it gets tough, market leader always pushing to expand the market, but there’s never enough illness.
Oh, there was talk about doing a few deals with their competitors, promote comorbidity; if there were no more patients, the ones they had would have to take more meds. No one wanted to go that route. A better strategy was to use more drug, double, triple, the dose. A higher dose wouldn’t provide any benefit in depression. A few early adopters had tried it, but it didn’t look good. Medical had already copied the case reports for Legal, just a matter of time before someone — FDA, Scientologists, chat-room crybabies — raised hell as if it were the coming of the Antichrist.
So the per-patient spend was a non-starter for depression, which was where OCD came in. The problem, what Soren’s boss called the challenge, was the limited market potential. OCD wasn’t common enough. Yes, there were dark nights imagining that the epidemiologists had it all wrong, our various obsessions — for pristine armpits, sterile countertops, pangyreic awareness — were so common now, so man-in-the-street pedestrian that they escaped notice. There under the radar, a plague of obsessions and compulsions waiting for a smart marketer to declare a pandemic. Just wishful thinking; Soren was forecasting a couple-three percent of the population as candidates for the drug. The only way to compensate was to use higher amounts, maybe four times the dose they were using for depression. But they needed to show proof of principle, feasibility. They needed the pilot study. They needed Munin to show it could be done.
Soren drafted a memo to Medical Affairs — May be a problem at the Montreal site. Recommend we consider someone else as principal investigator — but was overruled by the higher-ups. Munin was their first choice as PI. They wanted him to do the preliminary work. Munin had the reputation. He could attract other researchers to the project.
But not now. Not with an N-of-one study. It’s a disaster.
Affect calm. Smile. Probe gently. “Who, may I ask, is the patient?” Soren asks Munin.
“P.N. You understand I can’t give you her name.” Munin sees Soren struggling for an expression of infinite patience. “Call her Penelope.”
“This Penelope — she completed what, four months, six months?”
“Eighteen weeks. On the full dose.”
“And she responded? The drug works?” Soren sees Munin hesitate; doctors never like to commit themselves to anything definite. Tries to dial down the marketing angle. “It appears to provide some benefit, yes?”
Munin hesitates but has to agree there is some benefit. They achieved the primary endpoint: a fifty percent reduction in symptoms according to the questionnaires Munin has been filling out every week. Do you avoid public restrooms? Do you wash your hands over and over? Are you tense when you throw things away? Five questions on obsessions, five on compulsions. Yes or no, yes or no.
Are you afraid you will harm someone?
Do you think things should be arranged in a particular configu ration?
Do you have blasphemous thoughts?
Sexual thoughts?
“The treatment cut the severity of her symptoms in half,”
Soren says. “That’s an important gain.”
More of Munin’s famous caution. “A fifty percent reduction appears significant, but her scores were five times higher than normal when we started. She’s still very ill.”
“But the criterion was fifty percent. That’s how we defined response. It was decided. You agreed to it.”
Munin had agreed. His patient was objectively better. But what was the benefit, and what unintended harm had been done?
Soren doesn’t ask about Cynthia — that damn Swedish discretion. Munin figures he’s heard the story, but there are other stories. How cold it was that winter in Montreal, the wind tunnel of McGill College, the chill rolling down the mountain to the river. They took shelter in a half-deserted maison de torréfaction, the inviting damp of the overheated room, the cough and sputter of the machines. The afternoon passing in conversation, ordering coffees, maybe sharing something sweet. He and Cynthia and everything was new. She was animated then, talking about love or destiny,