There is evidence to support the idea that visual images may present an advantage over the spoken word with regard to learning reinforcement and knowledge retention (1). This may be related to the large amount of information that can be presented in a given amount of time or the ability of images to clarify otherwise complex concepts. It is also likely to be related to individual variation in the optimal sensory modality of learning, since some people seem to learn better from visual images than from written or spoken words alone.

The medium of film has been used in medicine and medical education since the late 1890s (2). From very early on, individual practitioners are reported to have filmed patients with various conditions for use in their lectures. Many of the films used in the first few decades of the 20th century focused on surgical procedures (3), health education, and disease prevention. There were also reports of films being used in "psychology and allied sciences" (4). Over the years, these medical films have been made by a wide variety of sources, including government departments, the armed services, universities, pharmaceutical companies, organizations interested in particular disorders, and individual practitioners. The availability of videocassettes, digital video discs (DVDs) and internet-based video has likely increased the accessibility of various types of material to practitioners, patients, and the general public.

The use of low-cost video cameras and home-video recording and editing equipment to make movies, specifically for medical education, has also been described (5). This is often done in the recording of patients with demonstrable pathology or to show a specific procedure. Additionally, it is often done in the context of filming student/patient interaction where the student later watches the video in order to improve interviewing or examination skills.

Finally, the use of commercially available films to teach medical students and residents about various aspects of psychiatry has been described (6—11). Some of the topics for which this has been explained include general psychopathology (6), psychiatric diagnosis (7), transference and countertransference (8), character analysis (9), suicide (10) and borderline personality disorder (11). To the author's knowledge, there have been no previous descriptions of the use of film to teach issues related to substance use disorders to medical students or residents. The purpose of the current study is to evaluate the students' perceived benefit of the inclusion of film clips in the teaching of intoxication and withdrawal syndromes.

A video home system (VHS) video tape was made by transferring brief clips (typically 10 to120 seconds in length) of various commercially available films as well as clips from several television news shows and a training film displaying intoxication and withdrawal syndromes made in the 1950s in the U.S. Public Health Service Narcotics Hospital in Lexington, Kentucky (This film is not commercially available; for the remainder of this paper, it will be referred to as the "Lexington Tape") (t1). This was done in the author's home with standard, nonprofessional video cassette recorder (VCR) and DVD players.

This video was shown as part of a 100-minute lecture on intoxication and withdrawal syndromes given to second-year medical students at the University of Maryland School of Medicine as part of their "pathophysiology and therapeutics" course. The structure of the lecture was as follows: 1) PowerPoint presentation introducing basic concepts of intoxication and withdrawal syndromes; 2) PowerPoint presentation with information (such as signs and symptoms, time course, management) on the intoxication syndrome seen with a specific substance (such as alcohol); 3) PowerPoint presentation with similar information on the withdrawal syndrome seen with that substance; 4) movie clips depicting the relevant intoxication syndrome (such as Leaving Las Vegas for alcohol intoxication); 5) movie clips depicting the relevant withdrawal syndrome (such as Lost Weekend for alcohol withdrawal). This general format was repeated for 11 major classes of substances of abuse: cocaine, amphetamines, hallucinogens, marijuana, phencyclidine, opioids, alcohol, sedatives, inhalants, steroids, and designer drugs.

Following the lecture, students in attendance were asked to complete an eight-question, written, anonymous questionnaire. In the questionnaire, they were asked to rate on a scale of 1 ("not at all") to 5 ("very much") questions such as "After this lecture, how comfortable do you feel in recognizing the various intoxication and withdrawal syndromes?" and "How much do you feel that the video footage will help you to remember the various intoxication and withdrawal syndromes?" The completed questionnaires were placed in a box in the front of the room or returned to the author via campus mail. Because there was a belief that there would not be any potential for harm to the students who completed the questionnaire, the Institutional Review Board of the University of Maryland School of Medicine granted a waiver for this study.

Out of a class of 135 second-year medical students, 122 (90%) attended the lecture. Of these, 89 completed the anonymous questionnaire for a response rate of 73% (t2). When asked "Prior to this, did you feel knowledgeable about intoxication and withdrawal from various substances of abuse?", 19 students (21%) rated a 4 or 5, and 29 (33%) rated a 1 or 2. When asked how comfortable they felt at recognizing these syndromes after the lecture, 78 students (88%) rated a 4 or 5 and none rated a 1 or 2. Eighty-three students (93%) rated a 4 or 5 when asked if they were better able to appreciate the medical severity of some intoxication and withdrawal syndromes. When asked how much they believed the video footage would help them to remember the various intoxication and withdrawal syndromes, 82 students (92%) rated a 4 or 5, and none rated a 1 or 2.

Students tended to find all three types of clips used (Lexington Tape, commercial movies, television news shows) to be equally beneficial and effective. When asked how useful both the commercial movies and television news shows were at conveying the syndromes, 82 students (92%) rated a 4 or 5, and none rated a 1 or 2. For the Lexington Tape, 81 students (91%) rated a 4 or 5, but seven (8%) rated a 1 or 2, largely based on the relatively poor visual and sound quality due to its age.

A space was left at the bottom of the questionnaire for written comments. Some of these comments included: "One scene is worth 1,000,000,000,000 words;" "I'm sure this will stick in my mind;" "I am very interested in substance abuse and consider myself to be fairly knowledgeable and I still found the videos to be very helpful;" and "It kept me interested." Two of the students commented on the obvious "home-made" nature of the video, but they did not feel that this affected its effectiveness.

Hyler (10) discusses some advantages to using "Hollywood" portrayals of psychopathology as compared to videotapes of actual patients. He mentions that "a good deal of thought (and money) has gone into the often high production values of these films, resulting in graphic, dramatic, and often prototypic illustrations that are not easily found in "real life (p. 216)." This is certainly true, and the dramatic effect may help the student to remember the desired material, but it is important to keep in mind that these portrayals may also be exaggerated and misleading. The educator must be aware of this potential and be sure to point these issues out to the students. A good example of this is in the movie Trainspotting when, after presumably being administered intravenous naloxone following a heroin overdose, the main character is revived within 2 to 3 seconds. It is important that students know that medication works quickly but never as fast as 2 to 3 seconds (the onset of action of naloxone being 60-90 seconds).

Another potential benefit of the use of film clips in the teaching of intoxication and withdrawal syndromes is that it provides a way to show clinical syndromes related to substances, such as phencyclidine (PCP), that may be relatively rare in certain areas of the country and syndromes, such as classic delirium tremens, that are relatively rare in general. A student may go through his or her four years of medical school without ever seeing a patient who has used PCP, but the memory of an accurately portrayed movie depiction may be very useful should that student see such a patient later in his or her career.

Certainly, the use of video clips of real patients can also be a very powerful tool. In the present case, the video footage from the U.S. Public Health Service Narcotics Hospital in Lexington, Kentucky shows intoxication and withdrawal syndromes in real patients. There are several problems with this, however. First, the tape is not commercially available and would be difficult to widely disseminate. Second, this tape was made in the 1950s before close attention was paid to issues of informed consent and confidentiality. In the current medical climate, these two issues may make the use of video footage of patients very cumbersome, if not impossible, to handle in certain situations (such as with the delirious patient who can not provide informed consent). However, if the situation arises and issues of informed consent and confidentiality can be adequately addressed, it may be very useful to videotape a patient.

The movies used here are only examples of the many movies and television news shows that depict intoxication and withdrawal syndromes. In 1999, The Office of National Drug Control Policy and the Department of Health and Human Service's Substance Abuse and Mental Health Services Administration (SAMHSA) sponsored a study (12) that found that 98% of the 200 most popular movie rentals of 1996 and 1997 depicted substance use. More than 90% of the movies depicted alcohol and/or tobacco use while twenty two percent depicted illicit drug use. Twenty six percent of the movies that depicted illicit drugs contained graphic portrayals of drug ingestion and/or preparation. Obviously, there is a wealth of material available in the popular culture.

Films might also be used to demonstrate other aspects of substance use disorders such as lifestyle, preparation and actual use of the substance, negative consequences, countertransference, effects on the family, and political/economic issues. Some of these would be difficult, if not impossible, (not to mention, illegal) for the student to appreciate through a lecture, demonstration, or any other forum. Lists available elsewhere (12,13,14) can be used to identify other movies that may be useful in education. Network television shows, both dramas (such as ER) and comedies (such as The Simpsons) often have issues related to substance use as minor or major themes in their plots. In addition, various news shows such as Dateline, 20/20, and 60 Minutes frequently have segments related to substance use and substance use disorders.

An important issue to address is the legality of using film clips to teach. Section 110 (1) of the U.S. Copyright Act (15, p. 21-22) states that "…the following are not infringements of copyright: (1) performance or display of a work by instructors or pupils in the course of face-to-face teaching activities of a nonprofit educational institution, in a classroom or similar place devoted to instruction…" A key factor is that these film clips be used strictly for the purposes of education. To show a film clip as part of a graduation ceremony, for example, where education is not the main purpose of the event would be an infringement of U.S. copyright law. Although the teaching is intended to be "face-to-face," section 110(2) of the same act provides for the transmission of a work if "(A) the performance or display is a regular part of the systemic instructional activities of a government body or a nonprofit educational institution; and (B) the performance or display is directly related and of material assistance to the teaching content of the transmission; and (C) the transition is made primarily for (i) reception in classrooms or similar places normally devoted to instruction, or (ii) reception by persons to whom the transmission is directed because their disabilities or other special circumstances prevent their attendance in classrooms or similar places normally devoted to instruction…"

There are some obvious limitations to this study. Approximately 10% of the class did not attend the lecture. It is possible that these students were less interested in the topic of substance use disorders and would have benefited less from the lecture and the video clips. Alternatively, these students may have been the ones who could have benefited the most. (Anecdotally, the author has noticed a significant increase in the number of students who attend this lecture since the introduction of the video clips 3 years ago). As this was done anonymously, it is also difficult to determine if the 27% of the attendees who did not complete the questionnaire may have felt different about the film clips. Additionally, these results are based entirely on student self-reports of how helpful they believe these video clips are. This does not indicate an actual increase in retention of knowledge due to the use of the video clips. (Anecdotally, the author has had students approach him 1 or 2 years after seeing these video clips and comment on the fact that they continue to remember the syndromes because of the clips). Finally, these results represent the opinions of one class of medical students at a single medical school.

Teaching medical students can often be challenging. Teaching medical students about addiction is usually even more challenging. Both, societal stereotypes and personal experiences tend to influence student's attitudes and, consequently, openness to learning about addiction. The use of popular film can help to make this process more interesting and, possibly, help to reduce some of the negative bias while at the same time conveying factual information.