Half a day at the movies: film studies in the VTS course

INTRODUCTION (training GPs, we reminded ourselves) the • To teach communication skills; For the last 3 years in our GP Vocational films should also have a serious underlying • To improve the doctors’ ability to Training sessions we have been showing theme or intention which might in some handle ethical problems. a full-length film once a term. We were way help those who saw them to reflect on already including the arts in the the human situation and become more METHOD curriculum in the form of visits to galleries helpful empathetic doctors for their We showed one complete film each term. and theatres and discussions of literary patients. So films that we felt to be pure The films were selected by the course novels. The hope is that this kind of entertainment, however blissful, were organisers (with one exception). They educational experience will promote a firmly, if regretfully, ruled out. were projected from video or DVD onto a greater empathy with patients as well as What sort of films satisfied our criteria? large screen to provide total immersion in broadening the general education of the As you might expect, they were mostly in the cinema dream world. So far we have GP registrars and SHOs. black and white and made between 1935 shown a different film each time, although Film has been widely used in the form and 1960. Oh yes, and in foreign in the course of 3 years there has been a of short extracts to trigger a discussion languages with English subtitles. What did turnover of registrars and SHOs. This has about particular practice situations (for we hope to achieve? Let me summarise given the course organisers the chance to example, a dying patient, unwanted our objectives. sample the impact of a variety of different pregnancy, family dysfunction and films. After tea, we had an unstructured breaking bad news).1 Students have been Our objectives: spontaneous discussion of the film. found to respond very readily to scenes, • To give the registrars an artistic mainly from mainstream films that experience that they would otherwise Films shown so far: resonate with problems that they have have missed. To show them something 1. Wild Strawberries, directed by Ingmar encountered in the hospital or GP setting. that they might want to see again and Bergmann, Sweden (1958) But we wanted to do something rather which might stay with them for life; 2. La Grande Illusion, directed by Jean different. • To help them see that the characters so Renoir. France (1940) To begin with we wanted to show brilliantly brought to life on the screen 3. Citizen Kane, directed by Orson Welles classic films which were good enough to were not very different from the US (1941) be widely acclaimed as works of art. That patients they engage with in the 4. Il Postino, directed by Michael Radford is, films which could take their place surgery. As a result they might be able Italy (1994) alongside classic works of literature, to view some difficult patients with 5. Les Enfants du Paradis, directed by drama, music and painting. For the same greater tolerance, sympathy and Marcel Carné, France (1945) reason we also wanted to show each film respect. They might be enabled to 6. Pather Panchali, directed by Satyajit from beginning to end. You can analyse a stand back a little from the symptoms Ray, India (1956). work of art and examine individual details and signs and see their patients as but you have to experience it as a whole to fellow human beings trying to make A BRIEF DESCRIPTION OF EACH begin with. We wanted to show our trainee sense of their lives and their emotions. FILM GPs the best that the cinema had The films do not show medical scenes Wild Strawberries (1958) produced over 100 years of existence. and are not really about doctors, In this early Ingmar Bergman classic, an That meant good scripts, good acting, although in one of them (Wild elderly microbiologist (wonderfully played beautiful evocative photography and Strawberries) the central character by the veteran Swedish director Victor skilful direction. Films with as near as happens to be a doctor; Sjöstrom) travels to his old university to be possible a single presiding auteur, • To share our own pleasure in these given a special award. He is a crusty old generally the director, tended to be great films with our group. fellow who lives with his loyal and adoring preferred. If the whole production was housekeeper. Despite his emotional touched by genius, so much the better. We We were not attempting: coldness, the doctor is troubled by his wanted the films to be entertaining, indeed • To provide talking points to illustrate distant relationship with his son and the entrancing. Seduction is an important part clinical problems; shaky state of the son’s marriage. He also of what cinema is about. But we felt that • To make people better doctors or has chilling premonitions of his own death, as our course has a serious purpose better human beings; which Bergman represents in some very

806 British Journal of General Practice, October 2005 Film Flora medica Richard Lehman From the journals, August–September 2005 arresting surreal scenes. Dr Borg decides New Eng J Med Vol 353 Forget it, 40% of them feel disempowered to travel in his old car (a magnificent 1937 555 Would we get osteoporotic bones back and emotionally exhausted. Packard) and his daughter-in-law offers to to full strength more quickly by adding JAMA Vol 294 accompany him. In the course of the long some parathyroid hormone to our bisphosphonates? This trial and the one on 681 The ‘growing epidemic of skin cancer’ drive the old doctor reviews his life: this is page 566 tried various ways to combine the may in part be due to greater vigilance (see an early example of a ‘road movie’ with an two, but there was no sustained benefit BMJ 331: 481 for melanoma) but rates of inner as well as an outer journey. They above alendronate alone. basal cell and squamous cell carcinoma in revisit a number of scenes from earlier 576 A big randomised trial confirming what young people have definitely risen in the stages in his life, including the the Cochrane review says — grommet Olmsted County study. summerhouse by the lake where he had insertion makes no difference to long-term 706 A meta-analysis of studies shows that family holidays and fell in love with his outcomes in glue ear. the longer you take warfarin, the less likely cousin, only to lose her to a bolder more 761 A revolution in the management of early you are to get a second thromboembolism. failed pregnancy — vaginal misoprostol can 819 Have you been following the Stent Wars? sensual rival. We see flashbacks of these spare surgery in 84% of incomplete There used to be battling fleets of stents, happy and painful scenes of his youth. The miscarriages or non-viable early bare, radioactive, or covered in various old man and his daughter-in-law begin to conceptions. chemicals, but the Force has favoured understand each other better. They give a 924 You won’t see much dengue fever in Sirolimus Eluting, Lord of the Stents. See also lift to three students, a vivacious young girl your practice, but you or your patients N Engl J Med (353: 653–663). (Bibi Andersson, who also plays the lost might well be thinking of going somewhere 947 A review of fetal perception of pain, sweetheart in the flashbacks) and her two where you could catch it — India, North citing good evidence that pain signals don’t rival boyfriends. The old doctor enjoys the Australia, Mexico. As this review explains, it reach the brain until about 29 weeks. isn’t nice and there isn’t any treatment. Wait 1043 Continuing medical education used to company of these young people who treat until there’s a quadrivalent vaccine. mean sleep-learning at lectures, so it him with affection and respect. Back on 977 The direct thrombin inhibitors hold out doesn’t surprise me that internet-based the road, they pick up another couple the promise of being the best oral CME can be more effective. You can go and whose marriage is clearly a disaster. Their anticoagulants, without the need for get a coffee any time. cruel sarcastic behaviour shocks the monitoring. Unfortunately the leading drug, others (and reminds Borg of his own failed ximelagatran, can damage the larynx of Other Journals marriage). those who try to utter it, and the liver in Arch Intern Med (165: 1686) looks at whether They visit Borg’s elderly unsentimental some patients who swallow it. normal doses of pseudoephedrine can affect blood pressure and pulse rate — yes, by mother. The car is refuelled by an Lancet Vol 366 1mmHg and 3 bpm. On page 1698, the appreciative ex-patient who remembers 455 The general superiority of aromatase vexed question of physician participation in when Dr Borg was a young country GP. inhibitors for preventing recurrence in post- euthanasia is examined from the experience Finally they arrive at Lund where Borg menopausal, oestrogen-receptor positive of 3614 Dutch GPs: it can be done within a receives his degree to the delight of his breast cancer is further demonstrated in this rational and humane legal framework. The young friends. Discussions take place trial, which switched women over from withholding of artificial hydration and feeding with his son and daughter-in-law that tamoxifen to anastrozole after 2 years, and in advanced dementia is considered on page encourage some hope that their marriage found they did better. Time to audit your 1729. Ann Intern Med (143: 241) presents a might be saved. tamoxifen prescribing. strong case for warfarin plus aspirin in all 549 Antiretroviral treatment cannot myocardial infarct survivors at low risk of In a final dream sequence we see the eliminate HIV completely from resting T- bleeding. On page 251, the Diabetes old man back at the summerhouse, cells, but there is an exciting new drug that Prevention Program is reviewed wistfully: greeting his parents who wave to him might — sodium valproate. small successes at great cost. As a classical from the distance. The last scene shows 563 At last, roflumilast. This is the name of migraineur, I keep an eye on the literature him dying peacefully having reached the a phosphodiesterase-4 inhibitor which, linking migraine with brain damage. Brain end of his life’s journey. according to this short-term trial, may be (128: 2068) presents MRI evidence of micro- our first really useful oral drug for chronic infarcts in 7.5% of patients who have La Grande Illusion (1939) obstructive pulmonary disease. migraine with aura — most of them in the 660 A lot of paediatric screening has not cerebellum. No wonder I keep making typos Here is a film about the experience of survived critical scrutiny (see Arch Dis and bumping into things. There is a new and some French officers in a German POW Childhood (90: 925) for the most sacred cow better instrument for assessing very early camp during the first Word War. They of all — failure to thrive), but detection of dementia, according to Neurology (65: 559). include an upper class pilot, a lieutenant of permanent hearing loss at birth can make a ‘Use of the AD8 in conjunction with a brief working-class origin (Jean Gabin) a Jewish difference and screening is feasible. assessment of the participant could improve officer from a rich banking family and a 726 Do homoeopaths really believe that diagnostic accuracy in general practice.’ music hall actor. We seem them digging an water can contain therapeutic memories? I Expect one at your next annual appraisal. escape tunnel and putting on a vaudeville hope (but don’t expect) that this is the last we hear about it. Plant of the Month: Euonymus grandiflorus show. Their dinner table is greatly 742 Dreaming that you had fulfilled your A big semi-evergreen shrub with wine-dark improved by gourmet food parcels sent by brilliant destiny as a hospital consultant? leaves and spectacular fruit in autumn. the Jewish officer’s family. Then they are

British Journal of General Practice, October 2005 807 moved to another more secure prison in a conclusions. Welles’ performance is family in living in rural Bengal. The father Colditz-like castle where the commandant outstanding and the film introduced many is a benign but unworldly scholar who is is an aristocratic Prussian, brilliantly cinematic innovations especially in the often absent in what seem to be hopeless played by Erich von Stroheim, with his use of camera fluidity, deep focus and attempts to make a little money. The neck enclosed in a surgical brace that montage. Even if you don’t rate it as the mother tries desperately to make end comically symbolises his mental rigidity. best film of all time it is an overwhelming meet. The little boy (Apu) and his elder He likes and respects Boieldieu, the pilot, experience and an essential part of sister are full of curiosity about the village who, despite being technically an enemy, anyone’s cinema education. and the world beyond. An extremely aged is a member of his own class. The others Auntie completes the household. The film he regards with lofty contempt. Il Postino (1994) is full of poetry and has images of striking The film is of course well scripted and This film is an odd one out that, left to beauty. There is humour and also beautifully shot. Although its underlying ourselves, we would never have included. heartbreak before the end in which we see mood is serious, many of the scenes are However, one of the registrars pleaded its them setting off for a new life in the city. very funny and some are quite stirring. All cause very strongly and in the end we the characters arouse our sympathy, even agreed to show it and didn’t regret the WHAT DO THESE FILMS HAVE the stiff German officer because of his decision. The film tells the story of a shy TO SAY TO US? courtesy and his mourning for a vanished young postman living on an idyllic but Do the films have particular messages age when war was conducted by backward Italian Island, in the 1950s, who that may be helpful in coping with real life gentlemen. Renoir shows how falls in love with the prettiest girl in the human (doctor–patient) relationships? complicated human loyalties and affinities village. He finds himself delivering letters can be. The upper class officers have a to a literary celebrity, the Chilean poet Some examples: closeness that transcends nationality and Pablo Neruda who has had to go into exile • We need to examine our lives while war; the Frenchmen are all comrades but for his political views. The poet there is still time to change. If we try their positive feelings for each other are (beautifully played by the great French and overprotect ourselves from painful disturbed by differences of social class, character actor Phillipe Noiret), begins to feelings we may end up feeling cold race, religion, wealth and temperament. take an interest in the young man and and alone. (Wild Strawberries.) teaches him about poetry. As a result he is • We all share the human predicament. Citizen Kane (1941) able to woo his sweetheart with poetry Life would be better if we could be This is a very famous film which frequently and they get married. The postman poet friendly and have respect for each tops the lists of the best movies of all is played with wistful longing by Massimo other’s feelings. But there are so many time. The director (Orson Welles at the Troisi who sadly died soon after the prejudices which get in the way. They brilliant beginning of a flawed career) also picture was finished. The haunting music make us feel hostile and we limit our plays the central role of the millionaire by Luise Enrique Bacalov won an Oscar. compassion to people of our own newspaper editor, Charles Foster Kane. subgroup, whether it is nationality, The film is structured as an enquiry into Les Enfants du Paradis (1945) rank, race or religion. If we can’t the life of the recently dead celebrity to try In the latter years of the second world war escape from this prison, the ‘war’ will and find out what drove him and what sort and in the teeth of the Vichy regime in never end. (La Grande Illusion.) of man he really was. There is a mock France, the director Marcel Carné and his • The urge for power and control over newsreel which reviews the external facts: script writer Jacques Prévert recreated other people may be overwhelming. separated from his parents as a child, the ‘Street of Crime’ and it’s music hall But great power may lead to frustration inheriting a fortune, buying a newspaper theatre ‘Les Funambules’ from the Paris and loneliness rather than emotional and converting it into a sensational of the 1830s. In this dream world we are fulfilment. scandal sheet, running for president, mesmerised by the relationships between • Looking at someone’s life from being caught out in a love affair, retreating a brilliant but tormented mime artist, a different angles and exploring his to a grandiose castle with his mistress, mysterious slightly older woman with background can enhance our amassing a fantastic art collection and whom he is in love, a pretty soubrette understanding; but ultimately who finally dying alone in the midst of all his carrying a torch for the mime artist, an exactly we are remains rather wealth. A journalist interviews various key ambitious young actor who longs to play mysterious. (Citizen Kane.) figures in Kane’s life in order to find out Shakespeare, and a cynical gangster who • Poetry is open to everyone. A shy more, and further scenes of his life both also writes plays. The cast includes the young person can learn to express his private and public are revealed in celebrated actress and model Arletty and feelings through the power of words. flashback. There is an apparent Jean-Louis Barrault whose mime Finding an understanding father figure psychological explanation of Kane’s performances are unforgettable. may be just as important. (Il Postino.) character but Welles later dismissed this • Why is love so difficult? Why does the as ‘dollar book Freud’. Kane remains an Pather Panchali (1955) person I love most in all the world have enigma and we are left to draw our own The film follows the fortunes of a little eyes only for someone else? There is

808 British Journal of General Practice, October 2005 Film Mike Fitzpatrick The Blair backlash

something of the theatre about all One of the few highlights of Britain’s professionals in good health, not by human interactions. We are all trying to recent lacklustre election campaign was patients suffering acute or chronic illness perform for an audience of one.’ (Les the television ambush of Tony Blair by a or physical or mental disability. Rapid Enfants du Paradis.) woman complaining about her difficulty in access to any health professional may suit • Seen through a child’s eyes the world booking an appointment with her GP those who only occasionally attend the is a magical place. But why are grown more than 2 days ahead. It clearly came surgery; for those who are more frequent ups so troubled? For the mother, it is as a shock to the prime minister to attenders, continuity of care with a familiar difficult to be kind and considerate discover that one of the unintended doctor is more important — yet this is now consequences of his government’s major accorded a much lower priority. New when she feels totally responsible for primary care policy initiative — to Labour’s pandering to swing voters has the family and everyone else seems so guarantee patients an appointment with reinforced the ‘inverse care law’ (those self-centred and unaware of her needs. their GP within 48 hours — was that, in whose need for health service resources (Pather Panchali.) some cases, they could not get an is least receive the most, and vice versa) appointment more than 48 hours in the which Old Labour once identified as one THE NEXT STAGE future. The anticipated backlash over this of the defects of the NHS under the Our general impression is that the films humiliation has now arrived, in the form of Tories, to be remedied when the party have been well received, once the group a further government initiative to ensure returned to power.2 members got over the shock of looking that doctors provide both immediate and The imposition of targets on every GP monochrome images and having to read long-term appointments. surgery by central government destroys subtitles. Each was followed by a lively Health minister Lord Warner proposes local autonomy and flexibility. Doctors’ unstructured discussion, mainly centred action to ‘tackle restrictive booking and surgeries provide services in a very wide on the characters and their relationships. tighten tests on the 2-day GP target’.1 variety of communities with different The first part of Les Enfants du Paradis Although, before the election, the requirements and their appointment was so compelling that the group insisted government acclaimed GPs’ successes systems have evolved over the years in on seeing the second half the following in achieving targets for 48-hour access, response to these needs. No doubt term. At our latest end-of-term evaluation Lord Warner now sternly declares that some GPs are more flexible than others session there was a unanimous vote for ‘there is absolutely no justification for this in meeting demands for appointments. the film sessions to continue. target being used as an excuse for an But it is not surprising to find that an inflexible appointment system’. He attempt to impose a uniform national So far we have not made any detailed threatens ‘more robust checks’ to ensure incentive scheme on access to GP notes of the discussion or attempted to that there will be no further surgeries has made the system more evaluate the audience’s responses to the embarrassments for the prime minister rather than less inflexible. This is films. on this issue. It does not seem to have particularly the case at a time when the In the next year we intend to show one occurred to the government that its ill- major constraint on the provision of of the films each term and record the advised interference in GPs’ appointment appointments is not the inadequacy of discussion. We will then follow this up systems has itself fostered inflexibility. appointment systems but the shortage of with some interviews, with the aim of The government’s preoccupation with GPs and other primary care getting qualitative accounts of how the the problem of ‘access’ to GPs’ surgeries professionals. Indeed one of the factors films were received and what thoughts goes back to the 1997 election exacerbating the shortfall in the supply of and feelings they generated. We hope to campaign, when one of the focus groups appointments is the trend towards early present the results of this research in a so influential in New Labour strategy retirement in general practice, in part a year’s time. reported that concerns about getting result of the relentless stream of urgent appointments were running high interfering initiatives from government. among key sections of voters. The drive It seems that the government we John Salinsky to reorganise primary care to ensure that elected to run the country is more all patients could expect to see a GP concerned with running our surgeries. within 48 hours (or another primary care This is certainly proving detrimental to the professional within 24 hours) was interests of patients in primary health Acknowledgement backed with substantial resources and care. Can it be good for the country? I would like to thank my course organiser dedicated personnel. By 2004, the colleague Dr Caroline Dickinson for her targets were being met, but the perverse REFERENCES constant and enthusiastic support in the film consequences were also becoming 1. Department of Health. Patients get booking project and her helpful contribution to the apparent. ‘guarantee’ on NHS GP appointments [press release]. discussions. The biggest problem resulting from the (2005/0313) http://www.dh.gov.uk/Publications AndStatistics/PressReleases/PressReleasesNotices/fs/e fetish of 48-hour access is that it has put REFERENCES n?CONTENT_ID=4118856&chk=PUcZZF (accessed the demands of the ‘worried well’ before 12 Sep 2005). 1. Alexander M, Lenehan P, Pavlov A (eds). Cinemeducation: a comprehensive guide to using film the needs of the ‘seriously ill’. Focus 2. Tudor Hart J. The inverse care law. Lancet 1971; i: in medical education. Oxford: Radcliffe Medical Press groups are attended by middle class 405–412. Ltd, 2005.

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