- Email: [email protected]
THE ORGANISATION OF BREAST-CANCER SERVICES
849
patients. A third of these consultants treated only 1 case during the year, and more than half treated 5 cases or less. At the other extreme, 6 consultants treated 36 patients or more in the year, the maximum number treated by any single consultant being 52. Of the 1822 patients 141 were also treated by a radiotherapist and a further 44 by a radiotherapist alone. The remaining 60 cases in the year were treated either by consultants outside the region or by a general practitioner alone. treated 1822
Occasional
Survey
THE ORGANISATION OF BREAST-CANCER SERVICES
J. L.
E. G. KNOX
BYWATERS
Health Services Research Centre, Department of Social Medicine, University of Birmingham, Birmingham B15 2TJ
investigation of breast-cancer services in the West Midlands Region has shown little concentration of diagnostic and treatment facilities or expertise. Delays were identified which were attributable to patients, general practitioners, hospital doctors, and administrative processes. It is suggested that the service could be improved by more effective education both of patients and of doctors, and by a more structured system of care for breast-cancer patients. An efficient system is an essential prerequisite for a screening service.
Summary
An
Delays Table n shows the cumulative effect of patient delay before presentation, of general practitioner delay before referral, and of waiting-list time for an outpatient appointment. The form in which the data were recorded did not permit resolution of this cumulative delay into its component parts. However, within this period, opportunities for earlier diagnosis were apparently missed. For example, 4 cases were discovered at outpatient clinics whither the patients had been TABLE I-DISTRIBUTION OF CASES AMONGST CONSULTANTS IN
1972
INTRODUCTION
BECAUSE the anticipated benefits of screening for breast cancer are limited, a screening programme could not be seriously considered for any particular region or area unless the services for symptomatic disease were fully effective. Moreover an experimental breast-cancer screening service could not be undertaken without a system of management for its control and support. In addition, a screening programme would increase the workload of the biopsy services; and unless these could respond to the increased demand, the programme might compete for resources, to the detriment of patients presenting with symptomatic disease.
TABLE II-INTERVAL FROM ONSET OF SYMPTOMS TO FIRST OUTPATIENT APPOINTMENT IN
243
CASES OF BREAST CANCER
METHOD AND MATERIAL
The West Midlands Regional Cancer Registry provided a sample of 250 female breast-cancer patients registered in 1972 comprising 50 patients selected randomly from each of five age-groups: Under 40, 40 - 49, 50 - 59, 60 - 69 and 70+. Thus, by comparison with the age-distribution of all breastcancer patients in the region in 1972, those under 50 were deliberately over-represented and those 50 or over were under-represented in the sample, because it was thought possible that the comparative rarity of breast cancer in the younger age-
group might result in less prompt diagnosis and treatment. 4 sets of records could not be traced, and 3 patients were excluded because they had had a previous primary breast carcinoma and were therefore under special surveillance. Thus the final study was conducted on an age-stratified sample of 243 patients. Data which were already coded were provided on punchcards by the Cancer Registry, and additional data were abstracted from the Registry’s written records, entered on prepared forms, and transferred to punch-cards. Both sets of data were analysed with a counter-sorter. The Cancer Registry also provided the age-distribution of all cases of breast cancer in the region in 1972, and the distribution of patients among consultants. RESULTS
Dispersion of Services The 241 patients who attended hospital
were
dispersed
amongst 46 hospitals or nursing-homes and 116 consultants. This pattern is shown in relation to the total number of cases (1926) in the region in 1972 in table i. Excluding radiotherapists, 178 consultants in the region
TABLE III-INTERVAL BETWEEN FIRST OUTPATIENT APPOINTMENT AND DEFINITIVE TREATMENT IN
243
CASES OF BREAST CANCER
850 TABLE IV-TOTAL INTERVAL FROM ONSET OF SYMPTOMS TO COMMENCEMENT OF DEFINITIVE TREATMENT IN 243 BREAST-CANCER PATIENTS
1-1-1-1-_1
I
referred by their general practitioners for other conditions without discovery of their breast lumps-and 2 patients underwent hospital admissions for major surgery without discovery of breast lumps which they themselves knew to be present at the time, with the consequence that they were not treated until 12 and 13 months later. The interval between the first outpatient appointment and treatment is shown in table m. Most of this delay occurred before biopsy (where performed) rather than between biopsy and treatment. In most cases, this delay represents entirely time on the surgical waiting-list. In 11 cases however, it was largely attributable to other factors: patient refusal (1), intercurrent infection (1), misleading initial biopsy (1), and clinical
decision (8). The last 8 cases were all in the under-50 age-group: 2 were discharged from the clinic with nodules which were eventually 5 and 16 months later, after re-referral. The other 6 reviewed in the outpatient clinic on one or more occasions before the decision to perform a biopsy was taken, resulting in delays ranging from 6 weeks to 8 months. The combined patient and health service delay from the onset of symptoms to the commencement of treatment is shown in table iv.
biopsied, were
DISCUSSION
Present System
of Care
A leading article in The Lancet’ concluded: "A rational approach to the management [of breast cancer] now demands precise preoperative diagnosis, accurate clinical and pathological staging, and treatment planned according to the extent of the disease and the biological characteristics of the tumour and its host. The full rewards from this approach will be advanced only by awareness of the complexity of the problem and of the need for special skills in those treating the disease. The traditional practice of regarding the treatment of patients with early breast cancer as an emergency has served its time."
This might give the impression that it is current practo treat a breast lump like appendicitis, rushing the
tice
patient into precipitate
surgery. The present
study shows that this is not so and that entry to waiting-lists, both for the outpatient clinic and for admission, seems be usual. A second feature of current practice is the dispersion of responsibility and an apparent lack of special centres providing for the concentration of expertise and diagnostic facilities such as mammography, thermography, skeletal surveys, and frozen sections.
to
Components of Delays There is evidence that, for
tumours of similar grade, the more advanced stages have worse prognosis2 and that early detection reduces mortality.3 The interval between the onset of disease and the pa-
tient’s first consciousness of it cannot be measured, However, it was estimated in the experimental Health Insurance Plan (H.I.P.) screening programme, in New York that "lead-times" averaged about ten months.’ Much of this gain was obtained at the initial screen and it seems clear that, in any extended screening service depending on (say) annual examinations, the lead-time would usually be less. The benefits, costs, and risks of full-scale screening remain to be determined,s but the present investigation suggests ways in which delays could be reduced by measures short of a full screening programme. Inclusion of the breasts in routine examinations of patients examined for other conditions would have reduced delay: the extent to which doctors missed opportunities to detect the presence of breast cancer is a cause for concern. Effective education in self-palpation would also help, although the emotional and technical difficulties must be weighed. Further delays occurred between the awareness of symptoms and presentation for medical advice. The chief problem seems to be fear rather than ignorance: most women are aware that a lump in the breast can be cancerand those who know this tend to delay longer than those who do not.’ This presents a health-education challenge of considerable
subtlety. Unfortunately,
the available data did not allow us resolve the cumulative pre-hospital delay into the proportions attributable to the patients, to the general practitioners, and to the hospital-appointment systems. Information on these points is likely to remain inaccessible-except for specially mounted surveys-in any system as loosely structured as the present one. Delays between the first outpatient consultation and biopsy also left scope for considerable improvement. Some delays were due to the difficulties of the clinical decisions in young women where the risk of malignancy is relatively small, but it is evident with hindsight that the index of suspicion was sometimes unduly low. Even where the decision to perform a biopsy was taken at the initial outpatient appointment, the delays suffered by some patients were considerable. Less than half of those biopsied were admitted within two weeks of their outpatient appointment. (Patients with benign lumps probably wait even longer.8) Delays between biopsy and definitive treatment were generally quite short; and there seems to be little scope for improvement here, particularly if the standards recommended by The Lancet1 are followed. to
Conclusions As is well known a substantial part of, unecessary delays in treating breast cancer, and in many cases the critical delays, is due to the behaviour of the patients, This is probably related more to fear than to ignorance, and the problems of developing and monitoring an effective system of education are severe. In so far as repeated exhortation has failed to resolve these difficulties, there seems to be a need for properly designed experiments to discover more effective solutions. The behaviour of doctors, both general practitioners and specialists, who failed to detect breast lumps gave cause for concern. It might be unrealistic to insist that every woman attending her general practitioner should have her breast examined on every occasion, but itis reasonable to expect that breast palpation should be in-
851
cluded within the most limited examination carried out before referral to a consultant. It should certainly be performed on every patient admitted to hospital. Again, the solution depends on education, but the framework for that education probably requires some investment and ingenuity. The organisation of the hospital service itself was a third area in which delays might be reduced. Routinely collected information does not at present enable us to distinguish appointment waiting-times from delays before referral. However, even the interval from the first appointment to the start of treatment involved substantial delays-often far greater than the responsible clinicians would defend as reasonable. It is not possible from the evidence assembled here to assess the extent to which a concentration of facilities and canalisation of referral pathways would improve prognosis, nor to justify efforts to devise a more structured system of care. However, it is difficult to escape the conclusion that a well-defined system of referral could have accelerated some of the administrative steps, resulted in improved availability and development of necessary diagnostic facilities, and reduced delays which
Occasional Film
THOSE psychiatrists masochistic enough to endure the collective assaults of films such as Loach’s Family Life and Kubrick’s A Clockwork Orange may, understandably, be to
give
One Flew Over the Cuckoo’s Nest
exist. We thank Miss J. Powell and Miss B. M. Cornes, of the West Midlands Regional Cancer Registry, for their invaluable assistance in the provision of data and the tracing of patients’ records. REFERENCES 1. 2. 3.
Lancet, 1975, i, 1171. Bloom, H. J. G. Br. J. Cancer, 1965, 19, 228. Shapiro, S., Strax, P., Venet, L., Venet, W. Seventh National Cancer Con-
ference Proceedings, 1973. 4. Hutchinson, G. B., Shapiro, S. J. natn. Cancer Inst. 1968, 5. British Breast Group. Br. med. J. 1975, iii, 357. 6. Paterson, R., Aitken-Swan, J. Lancet, 1954, ii, 857. 7. Aitken-Swan, J., Paterson, R. Br. med. J. 1955, i, 623. 8. Vessey, M. P., Doll, R., Sutton, P. M. ibid. 1972, iii, 719.
41, 665.
and the brilliance and subtlety of the two central figures, played by Jack Nicholson and Louise Fletcher. McMurphy is not merely locked in a battle for his own survival with the hospital psychiatrists, the frigid nurse, and her indifferent attendants. He is engaged in shaking each of the extraordinary assortment of inadequates, depressives, and psychotics with whom he shares the ward into some form of independent existence of his own. It is not just a perceptive film about an American mental institution with its watch-towers, high fencing, and straight-jackets. It is about the nuisance that is the man
ONE FLEW OVER THE CUCKOO’S NEST
tempted
might in part be attributed to relative clinical inexperience of the disease. Such an organisation would have the additional virtues of serving as a basis for the further education of patients and doctors and of permitting the quality of the service to be regularly monitored. Meanwhile, it seems quite unjustifiable to superimpose an expensive and marginally effective screening service. We suggest that this conclusion will apply in many regions besides our own, and that such a programme should not be undertaken anywhere until the existing system is shown to be working efficiently and a satisfactory basis for developing a screening service is shown to
a
miss.
After all the theme sounds hackneyed, the setting a drearily familiar one, and the central protagonists simply and provocatively drawn. Yet to miss this film would be simply unforgiveable-better by far to miss one of the innumerable conferences or committees devoted to the management of the violent patient or the definition of psychopathy, subjects dealt with in the film, albeit in a novel and unorthodox fashion. To miss this film would be to miss a stylish and enjoyable opportunity to see why the image of psychiatry remains persistently murky and its role in the struggle between the individual and
society so hopelessly compromised. The hero is
Randolph McMurphy, a swaggering, mischiemanipulative rebel who swaps his penal farm for the opportunity of a more relaxed and comfortable life at a mental institution. There he proceeds to inject much colour and vitality into the dull, drab routine of the hospital ward and slowly earns the affection and admiration of the other patients and the hostility and dislike of most of the staff. He takes all the patients out on a hilarious sea-fishing trip and succeeds in passing them off as a distinguished gathering of senior psychiatrists relaxing from a conference. He brings a couple of delightful floozies and some booze into the hospital one night vous, and
and the resultant revelries leave the ward in a shambles and its occupants in a contented drunken stupor. In the process, he draws the ire of Nurse Ratched, a mephistophelean figure, all plastic and enamel, who supervises the ward with the efficiency and warmth of a Nazi gauleiter and who presides over the daily therapeutic group like a circus tamer putting a pride of toothless, mangey lions through its paces. Their confrontation is at once both robust and chilling but it is doomed to end in only one possible fashion. The manner of Nurse Ratched’s victory is as ghastly as it is predictable for McMurphy ends up leucotomised and the unpredictable, irascible, irrepressible animal is finally tamed. What marks this film as qualitatively different from others of its genre is the stylish and observant direction of Milos For-
constitutional nonconformist who is burdened with little other than an outsize insistence on the need to live for living’s sake and a niggling distaste for the security and peace to be found in simple acquiescence. At one unforgettable moment shades of the "silent majority" are conjured up when the fearsome Ratched overturns a ward group decision on the grounds that not all the patients eligible to vote have voted, imperiously ignoring the fact that those who have failed to exercise their prerogative have neither the wit nor the means to do otherwise. It is of course the old tale in a new setting of the classic American archetypal hero, the outsider who has no ties, no emotional baggage, no principles to hamstring him other than a vigorous and child-like enthusiasm for living and a resilient faith in the essential humanity of his fellows. McMurphy rides into the ward for all the world like a new-found Lone Ranger and, aided by a massive Tonto-style indian chief, who for reasons of his own pretends to be a deaf-mute, takes on the evil sheriff on behalf of the fearful and cowed townsfolk. In the end, conformity triumphs, although it is, one senses, a pyrrhic
victory. That individuals who are relatively harmless in themselves be goaded into violence is hardly an original observation. That new, sophisticated, and technological methods of control can be unthinkingly applied is not exactly novel either. It is a tribute to Forman’s masterly direction that McMurphy’s sudden eruption into violence and authority’s swift and shattering response are numbingly credible and realistic. One is left with the uneasy feeling that it is not in the cold-blooded misuse of psychiatric techniques nor in the whole-hearted application with malice aforethought of drugs, E.C.T., and psychosurgery that lurks the greatest danger but in the stony certainty, the absolute conviction of some psychiatric practitioners that their power and their authority is self-evidently and unquestionably can
incnrruntihle.
ANTHONY CLARE
patients. A third of these consultants treated only 1 case during the year, and more than half treated 5 cases or less. At the other extreme, 6 consultants treated 36 patients or more in the year, the maximum number treated by any single consultant being 52. Of the 1822 patients 141 were also treated by a radiotherapist and a further 44 by a radiotherapist alone. The remaining 60 cases in the year were treated either by consultants outside the region or by a general practitioner alone. treated 1822
Occasional
Survey
THE ORGANISATION OF BREAST-CANCER SERVICES
J. L.
E. G. KNOX
BYWATERS
Health Services Research Centre, Department of Social Medicine, University of Birmingham, Birmingham B15 2TJ
investigation of breast-cancer services in the West Midlands Region has shown little concentration of diagnostic and treatment facilities or expertise. Delays were identified which were attributable to patients, general practitioners, hospital doctors, and administrative processes. It is suggested that the service could be improved by more effective education both of patients and of doctors, and by a more structured system of care for breast-cancer patients. An efficient system is an essential prerequisite for a screening service.
Summary
An
Delays Table n shows the cumulative effect of patient delay before presentation, of general practitioner delay before referral, and of waiting-list time for an outpatient appointment. The form in which the data were recorded did not permit resolution of this cumulative delay into its component parts. However, within this period, opportunities for earlier diagnosis were apparently missed. For example, 4 cases were discovered at outpatient clinics whither the patients had been TABLE I-DISTRIBUTION OF CASES AMONGST CONSULTANTS IN
1972
INTRODUCTION
BECAUSE the anticipated benefits of screening for breast cancer are limited, a screening programme could not be seriously considered for any particular region or area unless the services for symptomatic disease were fully effective. Moreover an experimental breast-cancer screening service could not be undertaken without a system of management for its control and support. In addition, a screening programme would increase the workload of the biopsy services; and unless these could respond to the increased demand, the programme might compete for resources, to the detriment of patients presenting with symptomatic disease.
TABLE II-INTERVAL FROM ONSET OF SYMPTOMS TO FIRST OUTPATIENT APPOINTMENT IN
243
CASES OF BREAST CANCER
METHOD AND MATERIAL
The West Midlands Regional Cancer Registry provided a sample of 250 female breast-cancer patients registered in 1972 comprising 50 patients selected randomly from each of five age-groups: Under 40, 40 - 49, 50 - 59, 60 - 69 and 70+. Thus, by comparison with the age-distribution of all breastcancer patients in the region in 1972, those under 50 were deliberately over-represented and those 50 or over were under-represented in the sample, because it was thought possible that the comparative rarity of breast cancer in the younger age-
group might result in less prompt diagnosis and treatment. 4 sets of records could not be traced, and 3 patients were excluded because they had had a previous primary breast carcinoma and were therefore under special surveillance. Thus the final study was conducted on an age-stratified sample of 243 patients. Data which were already coded were provided on punchcards by the Cancer Registry, and additional data were abstracted from the Registry’s written records, entered on prepared forms, and transferred to punch-cards. Both sets of data were analysed with a counter-sorter. The Cancer Registry also provided the age-distribution of all cases of breast cancer in the region in 1972, and the distribution of patients among consultants. RESULTS
Dispersion of Services The 241 patients who attended hospital
were
dispersed
amongst 46 hospitals or nursing-homes and 116 consultants. This pattern is shown in relation to the total number of cases (1926) in the region in 1972 in table i. Excluding radiotherapists, 178 consultants in the region
TABLE III-INTERVAL BETWEEN FIRST OUTPATIENT APPOINTMENT AND DEFINITIVE TREATMENT IN
243
CASES OF BREAST CANCER
850 TABLE IV-TOTAL INTERVAL FROM ONSET OF SYMPTOMS TO COMMENCEMENT OF DEFINITIVE TREATMENT IN 243 BREAST-CANCER PATIENTS
1-1-1-1-_1
I
referred by their general practitioners for other conditions without discovery of their breast lumps-and 2 patients underwent hospital admissions for major surgery without discovery of breast lumps which they themselves knew to be present at the time, with the consequence that they were not treated until 12 and 13 months later. The interval between the first outpatient appointment and treatment is shown in table m. Most of this delay occurred before biopsy (where performed) rather than between biopsy and treatment. In most cases, this delay represents entirely time on the surgical waiting-list. In 11 cases however, it was largely attributable to other factors: patient refusal (1), intercurrent infection (1), misleading initial biopsy (1), and clinical
decision (8). The last 8 cases were all in the under-50 age-group: 2 were discharged from the clinic with nodules which were eventually 5 and 16 months later, after re-referral. The other 6 reviewed in the outpatient clinic on one or more occasions before the decision to perform a biopsy was taken, resulting in delays ranging from 6 weeks to 8 months. The combined patient and health service delay from the onset of symptoms to the commencement of treatment is shown in table iv.
biopsied, were
DISCUSSION
Present System
of Care
A leading article in The Lancet’ concluded: "A rational approach to the management [of breast cancer] now demands precise preoperative diagnosis, accurate clinical and pathological staging, and treatment planned according to the extent of the disease and the biological characteristics of the tumour and its host. The full rewards from this approach will be advanced only by awareness of the complexity of the problem and of the need for special skills in those treating the disease. The traditional practice of regarding the treatment of patients with early breast cancer as an emergency has served its time."
This might give the impression that it is current practo treat a breast lump like appendicitis, rushing the
tice
patient into precipitate
surgery. The present
study shows that this is not so and that entry to waiting-lists, both for the outpatient clinic and for admission, seems be usual. A second feature of current practice is the dispersion of responsibility and an apparent lack of special centres providing for the concentration of expertise and diagnostic facilities such as mammography, thermography, skeletal surveys, and frozen sections.
to
Components of Delays There is evidence that, for
tumours of similar grade, the more advanced stages have worse prognosis2 and that early detection reduces mortality.3 The interval between the onset of disease and the pa-
tient’s first consciousness of it cannot be measured, However, it was estimated in the experimental Health Insurance Plan (H.I.P.) screening programme, in New York that "lead-times" averaged about ten months.’ Much of this gain was obtained at the initial screen and it seems clear that, in any extended screening service depending on (say) annual examinations, the lead-time would usually be less. The benefits, costs, and risks of full-scale screening remain to be determined,s but the present investigation suggests ways in which delays could be reduced by measures short of a full screening programme. Inclusion of the breasts in routine examinations of patients examined for other conditions would have reduced delay: the extent to which doctors missed opportunities to detect the presence of breast cancer is a cause for concern. Effective education in self-palpation would also help, although the emotional and technical difficulties must be weighed. Further delays occurred between the awareness of symptoms and presentation for medical advice. The chief problem seems to be fear rather than ignorance: most women are aware that a lump in the breast can be cancerand those who know this tend to delay longer than those who do not.’ This presents a health-education challenge of considerable
subtlety. Unfortunately,
the available data did not allow us resolve the cumulative pre-hospital delay into the proportions attributable to the patients, to the general practitioners, and to the hospital-appointment systems. Information on these points is likely to remain inaccessible-except for specially mounted surveys-in any system as loosely structured as the present one. Delays between the first outpatient consultation and biopsy also left scope for considerable improvement. Some delays were due to the difficulties of the clinical decisions in young women where the risk of malignancy is relatively small, but it is evident with hindsight that the index of suspicion was sometimes unduly low. Even where the decision to perform a biopsy was taken at the initial outpatient appointment, the delays suffered by some patients were considerable. Less than half of those biopsied were admitted within two weeks of their outpatient appointment. (Patients with benign lumps probably wait even longer.8) Delays between biopsy and definitive treatment were generally quite short; and there seems to be little scope for improvement here, particularly if the standards recommended by The Lancet1 are followed. to
Conclusions As is well known a substantial part of, unecessary delays in treating breast cancer, and in many cases the critical delays, is due to the behaviour of the patients, This is probably related more to fear than to ignorance, and the problems of developing and monitoring an effective system of education are severe. In so far as repeated exhortation has failed to resolve these difficulties, there seems to be a need for properly designed experiments to discover more effective solutions. The behaviour of doctors, both general practitioners and specialists, who failed to detect breast lumps gave cause for concern. It might be unrealistic to insist that every woman attending her general practitioner should have her breast examined on every occasion, but itis reasonable to expect that breast palpation should be in-
851
cluded within the most limited examination carried out before referral to a consultant. It should certainly be performed on every patient admitted to hospital. Again, the solution depends on education, but the framework for that education probably requires some investment and ingenuity. The organisation of the hospital service itself was a third area in which delays might be reduced. Routinely collected information does not at present enable us to distinguish appointment waiting-times from delays before referral. However, even the interval from the first appointment to the start of treatment involved substantial delays-often far greater than the responsible clinicians would defend as reasonable. It is not possible from the evidence assembled here to assess the extent to which a concentration of facilities and canalisation of referral pathways would improve prognosis, nor to justify efforts to devise a more structured system of care. However, it is difficult to escape the conclusion that a well-defined system of referral could have accelerated some of the administrative steps, resulted in improved availability and development of necessary diagnostic facilities, and reduced delays which
Occasional Film
THOSE psychiatrists masochistic enough to endure the collective assaults of films such as Loach’s Family Life and Kubrick’s A Clockwork Orange may, understandably, be to
give
One Flew Over the Cuckoo’s Nest
exist. We thank Miss J. Powell and Miss B. M. Cornes, of the West Midlands Regional Cancer Registry, for their invaluable assistance in the provision of data and the tracing of patients’ records. REFERENCES 1. 2. 3.
Lancet, 1975, i, 1171. Bloom, H. J. G. Br. J. Cancer, 1965, 19, 228. Shapiro, S., Strax, P., Venet, L., Venet, W. Seventh National Cancer Con-
ference Proceedings, 1973. 4. Hutchinson, G. B., Shapiro, S. J. natn. Cancer Inst. 1968, 5. British Breast Group. Br. med. J. 1975, iii, 357. 6. Paterson, R., Aitken-Swan, J. Lancet, 1954, ii, 857. 7. Aitken-Swan, J., Paterson, R. Br. med. J. 1955, i, 623. 8. Vessey, M. P., Doll, R., Sutton, P. M. ibid. 1972, iii, 719.
41, 665.
and the brilliance and subtlety of the two central figures, played by Jack Nicholson and Louise Fletcher. McMurphy is not merely locked in a battle for his own survival with the hospital psychiatrists, the frigid nurse, and her indifferent attendants. He is engaged in shaking each of the extraordinary assortment of inadequates, depressives, and psychotics with whom he shares the ward into some form of independent existence of his own. It is not just a perceptive film about an American mental institution with its watch-towers, high fencing, and straight-jackets. It is about the nuisance that is the man
ONE FLEW OVER THE CUCKOO’S NEST
tempted
might in part be attributed to relative clinical inexperience of the disease. Such an organisation would have the additional virtues of serving as a basis for the further education of patients and doctors and of permitting the quality of the service to be regularly monitored. Meanwhile, it seems quite unjustifiable to superimpose an expensive and marginally effective screening service. We suggest that this conclusion will apply in many regions besides our own, and that such a programme should not be undertaken anywhere until the existing system is shown to be working efficiently and a satisfactory basis for developing a screening service is shown to
a
miss.
After all the theme sounds hackneyed, the setting a drearily familiar one, and the central protagonists simply and provocatively drawn. Yet to miss this film would be simply unforgiveable-better by far to miss one of the innumerable conferences or committees devoted to the management of the violent patient or the definition of psychopathy, subjects dealt with in the film, albeit in a novel and unorthodox fashion. To miss this film would be to miss a stylish and enjoyable opportunity to see why the image of psychiatry remains persistently murky and its role in the struggle between the individual and
society so hopelessly compromised. The hero is
Randolph McMurphy, a swaggering, mischiemanipulative rebel who swaps his penal farm for the opportunity of a more relaxed and comfortable life at a mental institution. There he proceeds to inject much colour and vitality into the dull, drab routine of the hospital ward and slowly earns the affection and admiration of the other patients and the hostility and dislike of most of the staff. He takes all the patients out on a hilarious sea-fishing trip and succeeds in passing them off as a distinguished gathering of senior psychiatrists relaxing from a conference. He brings a couple of delightful floozies and some booze into the hospital one night vous, and
and the resultant revelries leave the ward in a shambles and its occupants in a contented drunken stupor. In the process, he draws the ire of Nurse Ratched, a mephistophelean figure, all plastic and enamel, who supervises the ward with the efficiency and warmth of a Nazi gauleiter and who presides over the daily therapeutic group like a circus tamer putting a pride of toothless, mangey lions through its paces. Their confrontation is at once both robust and chilling but it is doomed to end in only one possible fashion. The manner of Nurse Ratched’s victory is as ghastly as it is predictable for McMurphy ends up leucotomised and the unpredictable, irascible, irrepressible animal is finally tamed. What marks this film as qualitatively different from others of its genre is the stylish and observant direction of Milos For-
constitutional nonconformist who is burdened with little other than an outsize insistence on the need to live for living’s sake and a niggling distaste for the security and peace to be found in simple acquiescence. At one unforgettable moment shades of the "silent majority" are conjured up when the fearsome Ratched overturns a ward group decision on the grounds that not all the patients eligible to vote have voted, imperiously ignoring the fact that those who have failed to exercise their prerogative have neither the wit nor the means to do otherwise. It is of course the old tale in a new setting of the classic American archetypal hero, the outsider who has no ties, no emotional baggage, no principles to hamstring him other than a vigorous and child-like enthusiasm for living and a resilient faith in the essential humanity of his fellows. McMurphy rides into the ward for all the world like a new-found Lone Ranger and, aided by a massive Tonto-style indian chief, who for reasons of his own pretends to be a deaf-mute, takes on the evil sheriff on behalf of the fearful and cowed townsfolk. In the end, conformity triumphs, although it is, one senses, a pyrrhic
victory. That individuals who are relatively harmless in themselves be goaded into violence is hardly an original observation. That new, sophisticated, and technological methods of control can be unthinkingly applied is not exactly novel either. It is a tribute to Forman’s masterly direction that McMurphy’s sudden eruption into violence and authority’s swift and shattering response are numbingly credible and realistic. One is left with the uneasy feeling that it is not in the cold-blooded misuse of psychiatric techniques nor in the whole-hearted application with malice aforethought of drugs, E.C.T., and psychosurgery that lurks the greatest danger but in the stony certainty, the absolute conviction of some psychiatric practitioners that their power and their authority is self-evidently and unquestionably can
incnrruntihle.
ANTHONY CLARE